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<front>
<journal-meta>
<journal-id journal-id-type="publisher-id">Front. Oral. Health</journal-id>
<journal-title>Frontiers in Oral Health</journal-title>
<abbrev-journal-title abbrev-type="pubmed">Front. Oral. Health</abbrev-journal-title>
<issn pub-type="epub">2673-4842</issn>
<publisher>
<publisher-name>Frontiers Media S.A.</publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id pub-id-type="doi">10.3389/froh.2024.1375186</article-id>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Oral Health</subject>
<subj-group>
<subject>Systematic Review</subject>
</subj-group>
</subj-group>
</article-categories>
<title-group>
<article-title>Tendency of microbial adhesion to denture base resins: a systematic review</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author"><name><surname>Alqarawi</surname><given-names>Firas K.</given-names></name><uri xlink:href="https://loop.frontiersin.org/people/2738969/overview"/>
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<role content-type="https://credit.niso.org/contributor-roles/investigation/"/>
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<role content-type="https://credit.niso.org/contributor-roles/supervision/"/>
<role content-type="https://credit.niso.org/contributor-roles/validation/"/>
<role content-type="https://credit.niso.org/contributor-roles/visualization/"/>
<role content-type="https://credit.niso.org/contributor-roles/writing-original-draft/"/>
<role content-type="https://credit.niso.org/contributor-roles/writing-review-editing/"/>
</contrib>
<contrib contrib-type="author" corresp="yes"><name><surname>Gad</surname><given-names>Mohammed M.</given-names></name>
<xref ref-type="corresp" rid="cor1">&#x002A;</xref><uri xlink:href="https://loop.frontiersin.org/people/2638111/overview"/>
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<aff><institution>Department of Substitutive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University</institution>, <addr-line>Dammam</addr-line>, <country>Saudi Arabia</country></aff>
<author-notes>
<fn fn-type="edited-by"><p><bold>Edited by:</bold> Sigrun Eick, University of Bern, Switzerland</p></fn>
<fn fn-type="edited-by"><p><bold>Reviewed by:</bold> Janaina Habib Jorge, S&#x00E3;o Paulo State University, Brazil</p>
<p>Sudipto Datta, Indian Institute of Science (IISc), India</p></fn>
<corresp id="cor1"><label>&#x002A;</label><bold>Correspondence:</bold> Mohammed M. Gad <email>mmjad@iau.edu.sa</email></corresp>
</author-notes>
<pub-date pub-type="epub"><day>16</day><month>05</month><year>2024</year></pub-date>
<pub-date pub-type="collection"><year>2024</year></pub-date>
<volume>5</volume><elocation-id>1375186</elocation-id>
<history>
<date date-type="received"><day>23</day><month>01</month><year>2024</year></date>
<date date-type="accepted"><day>07</day><month>05</month><year>2024</year></date>
</history>
<permissions>
<copyright-statement>&#x00A9; 2024 Alqarawi and Gad.</copyright-statement>
<copyright-year>2024</copyright-year><copyright-holder>Alqarawi and Gad</copyright-holder><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/4.0/">
<p>This is an open-access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License (CC BY)</ext-link>. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.</p></license>
</permissions>
<abstract>
<sec><title>Objectives</title>
<p>Digital denture fabrication became an alternative method to conventional denture fabrication. However reviewing the antimicrobial performance of newly introduced digital fabrication methods in comparison to the conventional method is neglected. Aim of study: this review was to compare the antiadherence properties of various CAD-CAM subtractive (milled), additive (3D printed) conventional denture base resins. In order to answer the developed PICO question: &#x201C;Does CAD-CAM milled and 3D printed denture base resins have microbiological antiadherence properties over the conventional ones?&#x201D; We included comparative studies on digitally fabricated Denture base resins with conventionally fabricated one in term of microbial adhesion.</p>
</sec>
<sec><title>Methods</title>
<p>All <italic>in vitro</italic> studies investigated the microbial adherence to CAD-CAM milled and 3D printed denture base resins in comparison to conventional were searched in the PubMed, Web of Sciences, and Scopus databases up to December 2023.</p>
</sec>
<sec><title>Results</title>
<p>Fifteen studies have been investigated the microbial adhesion to milled and 3D printed denture base resins. CAD-CAM milled resins significantly decreased the microbial adhesion when compared with the conventional resins and 3D printed resins, while the later showed a high tendency for microbial adhesion. The addition of antifungal agents to 3D printed resins significantly reduced <italic>C. albicans</italic> adhesion. In terms of 3D printing parameters, printing orientation affected adherence while printing technology had no effect on microbial adhesion.</p>
</sec>
<sec><title>Conclusion</title>
<p>Denture base materials and fabrication methods significantly affect the microbial adhesion. CAD-CAM milled denture base resins demonstrated low microbial adhesion. 3D-printed resins showed high tendency for <italic>C. albicans</italic> adhesion. The antiadherent properties of 3D-printed resins can be improved by incorporating antifungal agents or changing the printing parameters, but further investigations are required to validate these modifications.</p>
</sec>
</abstract>
<kwd-group>
<kwd>3D printing</kwd>
<kwd>CAD-CAM milled</kwd>
<kwd>microbial adhesion</kwd>
<kwd>complete dentures</kwd>
<kwd>digital dentures</kwd>
</kwd-group>
<counts>
<fig-count count="1"/>
<table-count count="4"/><equation-count count="0"/><ref-count count="45"/><page-count count="0"/><word-count count="0"/></counts><custom-meta-wrap><custom-meta><meta-name>section-at-acceptance</meta-name><meta-value>Oral Infections and Microbes</meta-value></custom-meta></custom-meta-wrap>
</article-meta>
</front>
<body>
<sec id="s1" sec-type="intro"><label>1</label><title>Introduction</title>
<p>The most common clinical problem associated with patients wearing complete dentures is denture stomatitis (DS). This infection is primarily caused by <italic>Candida albicans</italic> adhesion to the denture base surface (<xref ref-type="bibr" rid="B1">1</xref>). Surface properties are considered the most important factor in <italic>C. albicans</italic> adhesion and colonization, along with other factors such as poor oral hygiene and ill-fitting dentures (<xref ref-type="bibr" rid="B2">2</xref>). It was reported that DS occurrence rate is about 30&#x0025;&#x2013;75&#x0025; of denture wearers and high recurrence rate even with antifungal treatment (<xref ref-type="bibr" rid="B3">3</xref>). This situation increased as the surface properties change (increasing Ra and contact angle and decreasing hardness) where rougher surfaces act as a nest and become an adequate environment for microbial adhesion and colonization (<xref ref-type="bibr" rid="B2">2</xref>). The surface properties of denture base resins affected by the fabrication method, and CAD-CAM milled denture base resins had superior surface properties (<xref ref-type="bibr" rid="B4">4</xref>&#x2013;<xref ref-type="bibr" rid="B6">6</xref>). Therefore, denture base resins with smooth surfaces that are less appealing to microbial adhesion contributed to denture longevity when combined with healthy denture foundation tissue.</p>
<p>For digital denture fabrication, the use of computer-aided-design-computer-aided-manufacture (CAD-CAM) methods is becoming more popular. This is due to many advantages over conventional method such as reducing the number of appointments, laboratory time required for prostheses fabrication, reducing laboratory errors, and the ability to store data for future fabrication (<xref ref-type="bibr" rid="B7">7</xref>&#x2013;<xref ref-type="bibr" rid="B9">9</xref>). CAD-CAM fabricated prostheses demonstrated better adaption than conventionally-fabricated ones (<xref ref-type="bibr" rid="B10">10</xref>) in addition to their superior physical properties (<xref ref-type="bibr" rid="B11">11</xref>). CAD-CAM denture fabrication includes two methods; milling denture from prepolymerized Polymethylmethacrylate (PMMA) acrylic discs that polymerized under high pressure/temperature (subtractive method, SM) and building the denture in layers using photopolymerized resins (additive method, AM) also known as three-dimensionally (3D) printed denture base resins (<xref ref-type="bibr" rid="B12">12</xref>, <xref ref-type="bibr" rid="B13">13</xref>). SM is the most commonly used method because it was developed before AM and has superior mechanical properties when compared to AM (<xref ref-type="bibr" rid="B7">7</xref>). However, AM has some advantages such as no material waste and no milling bur deterioration (<xref ref-type="bibr" rid="B12">12</xref>). In addition to the fabrication methods, the composition of denture base materials material has a role in the in results variations. The conventional and CAD-CAM milled are PMMA-Based while 3D printed either PMMA- or ester-based light polymerized resin (<xref ref-type="bibr" rid="B7">7</xref>, <xref ref-type="bibr" rid="B11">11</xref>&#x2013;<xref ref-type="bibr" rid="B13">13</xref>).</p>
<p>Although AM advantages, there are some drawbacks such as low mechanical properties and poor surface characteristics (<xref ref-type="bibr" rid="B14">14</xref>). The low physical and mechanical performance of AM has been attributed to the printing method (layer-by-layer) and polymerization method (photo-polymerization) (<xref ref-type="bibr" rid="B12">12</xref>, <xref ref-type="bibr" rid="B14">14</xref>). Many attempts have been made to overcome these drawbacks by using different printing technologies, modifying printing parameters, and/or adding reinforcement and antimicrobial agents (<xref ref-type="bibr" rid="B15">15</xref>).</p>
<p>Studies have shown a relationship between <italic>C. albican</italic> adherence, colonization, and biofilm formation and the surface properties of denture base resins including roughness, porosities, and contact angle/hydrophilicity (<xref ref-type="bibr" rid="B1">1</xref>). Many studies (<xref ref-type="bibr" rid="B1">1</xref>, <xref ref-type="bibr" rid="B16">16</xref>&#x2013;<xref ref-type="bibr" rid="B18">18</xref>) compared surface properties of conventionally and CAD-CAM denture base resins in term of surface roughness and wettability and variation between findings was reported. Furthermore, surface roughness affected both hydrophobicity and adherence activities (<xref ref-type="bibr" rid="B13">13</xref>). While previous investigation demonstrated no linear relationship between the surface roughness of denture base resin and <italic>C. albican</italic> adhesion (<xref ref-type="bibr" rid="B19">19</xref>).</p>
<p>Authors of previous studies (<xref ref-type="bibr" rid="B1">1</xref>, <xref ref-type="bibr" rid="B16">16</xref>&#x2013;<xref ref-type="bibr" rid="B18">18</xref>) stated that the hydrophilic denture bases are less vulnerable to microbial adherence. CAD-CAM dentures base showed more wettability and showed reduced microbial adhesion compared with conventional one (<xref ref-type="bibr" rid="B1">1</xref>, <xref ref-type="bibr" rid="B4">4</xref>, <xref ref-type="bibr" rid="B5">5</xref>, <xref ref-type="bibr" rid="B11">11</xref>). Another study (<xref ref-type="bibr" rid="B5">5</xref>) found that milled and 3D printed denture base materials were biocompatible and had similar surface characteristics. Fouda et al. (<xref ref-type="bibr" rid="B20">20</xref>), found that there was no difference in surface roughness between 3D printed, milled, and conventional rein, and that the adherence of <italic>C. albicans</italic> to all resins behaved similarly. Due the variations in surface properties of denture base resins and amount of microbial adhesions, authors suggested evaluating different CAD-CAM systems with different resins materials.</p>
<p>There have been no previous studies reviewing the microbiological antiadherence properties of digitally fabricated denture base resins. This review was conducted to evaluate the microbial adherence properties of CAD-CAM fabricated denture base resins in comparison to conventional ones, as well as to answer the research question &#x201C;Does CAD-CAM milled and 3D printed denture base resins have microbiological antiadherence properties over to conventional ones?&#x201D;</p>
</sec>
<sec id="s2" sec-type="methods"><label>2</label><title>Materials and methods</title>
<sec id="s2a"><label>2.1</label><title>Focused question</title>
<p>PICOS (<xref ref-type="table" rid="T1">Table&#x00A0;1</xref>) revealed the following study question; &#x201C;Does CAD-CAM milled and 3D printed denture base resins have microbiological antiadherence properties over the conventional ones?&#x201D;</p>
<table-wrap id="T1" position="float"><label>Table 1</label>
<caption><p>PICO model.</p></caption>
<table frame="hsides" rules="groups">
<colgroup>
<col align="left"/>
<col align="left"/>
</colgroup>
<thead>
<tr>
<th valign="top" align="left" colspan="2">PICOS</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top" align="left">P: Participant</td>
<td valign="top" align="left">Denture base materials</td>
</tr>
<tr>
<td valign="top" align="left">I: Intervention</td>
<td valign="top" align="left">CAD/CAM (Milled and 3D printed) denture base resins</td>
</tr>
<tr>
<td valign="top" align="left">C: Comparison</td>
<td valign="top" align="left">Conventional heat-polymerized denture base</td>
</tr>
<tr>
<td valign="top" align="left">O: Outcome</td>
<td valign="top" align="left">Microbial adhesion</td>
</tr>
</tbody>
</table>
</table-wrap>
</sec>
<sec id="s2b"><label>2.2</label><title>Study design</title>
<p>To conduct this review, the preferred reporting items for systematic reviews and meta-analysis (PRISMA) recommendations (<xref ref-type="bibr" rid="B21">21</xref>) were followed.</p>
</sec>
<sec id="s2c"><label>2.3</label><title>Search strategy</title>
<p>Searching for relative published literatures up to December 2023 was done through PubMed, Web of sciences, and Scopus databases. For the research strategy, both controlled and non-controlled descriptors and Boolean terms (OR, AND) were used (<xref ref-type="table" rid="T2">Table&#x00A0;2</xref>).</p>
<table-wrap id="T2" position="float"><label>Table 2</label>
<caption><p>Search strategy.</p></caption>
<table frame="hsides" rules="groups">
<colgroup>
<col align="left"/>
<col align="left"/>
</colgroup>
<thead>
<tr>
<th valign="top" align="left">Databases</th>
<th valign="top" align="center">PubMed, scopus, and web of sciences</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top" align="left">Keywords &#x201C;Search combination&#x201D;</td>
<td valign="top" align="left">[&#x201C;Denture, Complete&#x201D; (mesh) OR &#x201C;Complete Denture&#x201D; OR &#x201C;Complete Dentures&#x201D; OR &#x201C;Dentures Complete&#x201D;]<break/>AND<break/>(&#x201C;Computer-Aided Design&#x201D; [mesh] OR &#x201C;Computer Aided Design&#x201D; OR &#x201C;Computer-Aided Designs&#x201D; OR &#x201C;Design, Computer-Aided&#x201D; OR &#x201C;Designs, Computer-Aided&#x201D; OR &#x201C;Computer-Assisted Design&#x201D; OR &#x201C;Computer Assisted Design&#x201D; OR &#x201C;Computer-Assisted Designs&#x201D; OR &#x201C;Design, Computer-Assisted&#x201D; OR &#x201C;Designs, Computer-Assisted&#x201D; OR &#x201C;Computer-Aided Manufacturing&#x201D; OR &#x201C;Computer Aided Manufacturing&#x201D; OR &#x201C;Manufacturing, Computer-Aided&#x201D; OR &#x201C;Computer-Assisted Manufacturing&#x201D; OR &#x201C;Computer Assisted Manufacturing&#x201D; OR &#x201C;Manufacturing, Computer-Assisted&#x201D; OR &#x201C;CAD-CAM&#x201D;)<break/>AND<break/>(&#x201C;3D printed&#x201D; OR &#x201C;additive manufacture&#x201D; OR &#x201C;RP Technologies&#x201D; OR &#x201C;Rapid Prototyping&#x201D; OR &#x201C;rapidly prototyped&#x201D; OR &#x201C;3D digital dentistry&#x201D; OR &#x201C;three-dimensional printing&#x201D;<break/>OR &#x201C;stereolithographic&#x201D; OR &#x201C;stereolithographically printed&#x201D;)<break/>AND<break/>((&#x201C;Denture stomatitis&#x201D; OR &#x201C;Candida&#x201D; OR &#x201C;bioflm&#x201D;) &#x201C;Microbial adhesion&#x201D; Antimicrobial agents; Antimicrobial efficacy, Candidiasis, Candida, Denture, Colonization, Stomatitis, <italic>Candida albicans</italic>)</td>
</tr>
<tr>
<td valign="top" align="left">Inclusion criteria</td>
<td valign="top" align="left">Full-text articles<break/>English language<break/>CAD-CAM denture base resins (milled and/or 3D printed) with or without comparison with Heat polymerized resin<break/>Microbial adhesion</td>
</tr>
<tr>
<td valign="top" align="left">Exclusion criteria</td>
<td valign="top" align="left">Other language rather than English<break/>Article didn&#x0027;t investigate microbial adhesion<break/>Only abstract<break/>Review articles, short communications, and case reports</td>
</tr>
</tbody>
</table>
</table-wrap>
</sec>
<sec id="s2d"><label>2.4</label><title>Inclusion and exclusion criteria</title>
<p>In vitro studies, full article published in English language studies investigated microbial adhesions to CAD-CAM manufactured denture base resins (Milled and 3D printed) and compared with conventionally fabricated were targeted and included. Other studies that did not investigate CAD-CAM denture base resins and had no microbial adhesion test were excluded. In addition to the fallowing excluded studies: not published in English, case reports, reviews, short communications, letters to the editor, and only available in abstract form (<xref ref-type="table" rid="T2">Table&#x00A0;2</xref>).</p>
</sec>
<sec id="s2e"><label>2.5</label><title>Study selection, data extraction, and method of analysis</title>
<p><xref ref-type="fig" rid="F1">Figure&#x00A0;1</xref> shows how all articles were screened for included studies selections. Following the deletion of duplicated studies, the title and abstract of each study were individually screened and analyzed by two authors (F.K.A. and M.M.G) in accordance with the inclusion criteria. Disagreements are resolved through discussion between the two authors. Following approval, the full text of relevant studies meeting the eligibility criteria was read, followed by data collection and tabulation (<xref ref-type="table" rid="T3">Table&#x00A0;3</xref>). Data was descriptively assessed in terms of microbial adhesion to the milled and 3D printed materials, and then compared to conventional denture base resins.</p>
<fig id="F1" position="float"><label>Figure 1</label>
<caption><p>PRISMA flow chart of the study selection process.</p></caption>
<graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="froh-05-1375186-g001.tif"/>
</fig>
<table-wrap id="T3" position="float"><label>Table 3</label>
<caption><p>Included studies investigated microbial adhesion to CAD-CAM denture base resins.</p></caption>
<table frame="hsides" rules="groups">
<colgroup>
<col align="left"/>
<col align="left"/>
<col align="left"/>
<col align="left"/>
<col align="left"/>
<col align="left"/>
<col align="left"/>
</colgroup>
<thead>
<tr>
<th valign="top" align="left">Author/year/type of study/title</th>
<th valign="top" align="center">Denture base type/processing methods</th>
<th valign="top" align="center">Specimens dimensions/aging</th>
<th valign="top" align="center">Microbial species</th>
<th valign="top" align="center">Count methods and mean values</th>
<th valign="top" align="center">Modifications/variable</th>
<th valign="top" align="center">Outcome</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top" align="left">Al-Fouzan et al., 2017 (<xref ref-type="bibr" rid="B22">22</xref>)</td>
<td valign="top" align="left">HP<break/>CAD/CAM Milling</td>
<td valign="top" align="left">Disc shape 3&#x2009;&#x00D7;&#x2009;10&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic><break/>NS</td>
<td valign="top" align="left">Colony-forming units (CFU)</td>
<td valign="top" align="left">Materials and fabrication methods</td>
<td valign="top" align="left">Less <italic>C. albicans</italic> adhesion to CAD/CAM fabricated denture bases compared with the conventional procedure.</td>
</tr>
<tr>
<td valign="top" align="left">Murat et al., 2019 (<xref ref-type="bibr" rid="B23">23</xref>)</td>
<td valign="top" align="left">HP<break/>CAD/CAM Milling</td>
<td valign="top" align="left">Disc shape 10&#x2009;&#x00D7;&#x2009;2&#x2005;mm)<break/>TC (10,000 cycles&#x2005;)</td>
<td valign="top" align="left"><italic>C. albicans</italic><break/>(ATCC 209)</td>
<td valign="top" align="left">Microscopic evaluation (Mean cell/field)</td>
<td valign="top" align="left">Uncoated and pellicle-coated specimens</td>
<td valign="top" align="left">Less <italic>C. albicans</italic> adhesion to CAD/CAM polymers when compared with conventional PMMA</td>
</tr>
<tr>
<td valign="top" align="left">Di Fiore et al., 2021 (<xref ref-type="bibr" rid="B24">24</xref>)</td>
<td valign="top" align="left">HP<break/>CAD-CAM milled<break/>3D-printed</td>
<td valign="top" align="left">Disc shape 10&#x2009;&#x00D7;&#x2009;3&#x2005;mm</td>
<td valign="top" align="left"><italic>L. salivarius</italic><break/>(ATCC 33592)<break/><italic>S.mutans</italic> (ATCC 25175)<break/><italic>C. albicans</italic><break/>(ATCC 18,804)</td>
<td valign="top" align="left">Colony-forming units (CFU)</td>
<td valign="top" align="left">Materials and fabrication methods Unpolished polished</td>
<td valign="top" align="left">CAD-CAM groups showed the lowest <italic>C. albicans</italic> adhesion with different incubation time.</td>
</tr>
<tr>
<td valign="top" align="left">Meirowitz et al., 2021 (<xref ref-type="bibr" rid="B25">25</xref>)</td>
<td valign="top" align="left">HP<break/>AP<break/>CAD-CAM milled<break/>3D printing</td>
<td valign="top" align="left">Disc shape 12&#x2009;&#x00D7;&#x2009;2&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic> (ES 58919)</td>
<td valign="top" align="left">Quantified using SEM</td>
<td valign="top" align="left">Materials and fabrication methods</td>
<td valign="top" align="left">CAD-CAM groups showed the lowest <italic>C. albicans</italic> adhesion followed by HP while 3D printing increased the microbial adhesion.</td>
</tr>
<tr>
<td valign="top" align="left">Shim et al., 2020 (<xref ref-type="bibr" rid="B26">26</xref>)</td>
<td valign="top" align="left">3D-printed</td>
<td valign="top" align="left">Disc shape 10&#x2009;&#x00D7;&#x2009;2&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic> (KCCM 11282)</td>
<td valign="top" align="left">SEM observation</td>
<td valign="top" align="left">Printing orientation as a variable</td>
<td valign="top" align="left">Printing orientation showed a variations in <italic>C. albicans</italic> adhesion while 0-degrees showed the highest proportion followed by 45-degree then 90-degrees.</td>
</tr>
<tr>
<td valign="top" align="left">Li et al., 2022 (<xref ref-type="bibr" rid="B27">27</xref>)</td>
<td valign="top" align="left">AP<break/>3D printing</td>
<td valign="top" align="left">Disc shape 10&#x2009;&#x00D7;&#x2009;2&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic><break/>NS</td>
<td valign="top" align="left">Relative metabolic activity</td>
<td valign="top" align="left">Printing technology and build angle</td>
<td valign="top" align="left">No significant between two AP and 3D printed denture in terms of <italic>C. albicans&#x2019;</italic> adhesion. Additionally, printing technology and building angle did not influence <italic>C. albicans</italic> adhesion.</td>
</tr>
<tr>
<td valign="top" align="left">Totu et al., 2017 (<xref ref-type="bibr" rid="B28">28</xref>)</td>
<td valign="top" align="left">3D printing</td>
<td valign="top" align="left">NS</td>
<td valign="top" align="left"><italic>C. scotti</italic><break/>NS</td>
<td valign="top" align="left">Dehydrogenase assays</td>
<td valign="top" align="left">0.2, 0.4, 0.6, 1, 2.5 by weight&#x0025; of TiO<sub>2</sub>NP</td>
<td valign="top" align="left">TiO<sub>2</sub> nanoparticles addition to 3D printed resins showed antibacterial effects, specifically on <italic>Candida species</italic>.</td>
</tr>
<tr>
<td valign="top" align="left">Jeon et al., 2022 (<xref ref-type="bibr" rid="B29">29</xref>)</td>
<td valign="top" align="left">3D-printing</td>
<td valign="top" align="left">Disc shape 15&#x2009;&#x00D7;&#x2009;5&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic>, (ATCC 10231)</td>
<td valign="top" align="left">Colony forming unit (CFU/ml)</td>
<td valign="top" align="left">Modified with phytoncide oil A&#x0026;B</td>
<td valign="top" align="left">Phytoncide A and B -modified 3D printed resin showed an optimum antifungal activities and improved surface properties with 6&#x2005;wt&#x0025; and 15&#x2005;wt&#x0025;.</td>
</tr>
<tr>
<td valign="top" align="left">Jeon et al., 2022b (<xref ref-type="bibr" rid="B30">30</xref>)</td>
<td valign="top" align="left">3D printing</td>
<td valign="top" align="left">Disc shape 15&#x2009;&#x00D7;5&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic> (ATCC 10231)</td>
<td valign="top" align="left">Microscopically observed</td>
<td valign="top" align="left">Phytoncide oil type A</td>
<td valign="top" align="left">In terms of the antifungal activities, 3D printed resins containing micro-encapsulation of 6&#x2005;wt&#x0025; phytoncide oil showed the most adequate situations for clinical use.</td>
</tr>
<tr>
<td valign="top" align="left">Freitas et al., 2022 (<xref ref-type="bibr" rid="B31">31</xref>)</td>
<td valign="top" align="left">HP<break/>CAD-CAM Milled<break/>3D printed</td>
<td valign="top" align="left">Disc shape 10&#x2009;&#x00D7;&#x2009;3&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic> SN 425</td>
<td valign="top" align="left">Colony forming unit<break/>CFU/ml</td>
<td valign="top" align="left">NS</td>
<td valign="top" align="left">CAD-CAM milled showed low C<italic>. albicans</italic> adhesion while 3D printed reins showed more <italic>C. albicans</italic> adhesion.</td>
</tr>
<tr>
<td valign="top" align="left">Barros et al., 2023 (<xref ref-type="bibr" rid="B32">32</xref>)</td>
<td valign="top" align="left">Thermal-polymerized<break/>3D printed</td>
<td valign="top" align="left">Rectangular 20&#x2009;&#x00D7;&#x2009;10&#x2009;&#x00D7;&#x2009;2&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic> (ATCC 10231)</td>
<td valign="top" align="left">Colony forming units (CFU/ml); Staining with crystal violet followed by optical density reading</td>
<td valign="top" align="left">NS</td>
<td valign="top" align="left">Thermos-polymerized resin shoed more <italic>C. albicans</italic> when compared with 3D printed resin</td>
</tr>
<tr>
<td valign="top" align="left">Li et al., 2023 (<xref ref-type="bibr" rid="B33">33</xref>)</td>
<td valign="top" align="left">PMMA &#x2013;ve<break/>3D printed</td>
<td valign="top" align="left">Disc shape 10&#x2009;&#x00D7;&#x2009;2&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic></td>
<td valign="top" align="left">Cell counting kit-8 assay fluorescence microscopy optical density</td>
<td valign="top" align="left">Printing-layer thickness and build angle</td>
<td valign="top" align="left">Printing layer thickness affect <italic>C. albicans</italic> adhesion while orientations has no effect.</td>
</tr>
<tr>
<td valign="top" align="left">Koujan et al., 2023 (<xref ref-type="bibr" rid="B34">34</xref>)</td>
<td valign="top" align="left">PMMA CAD-CAM milled<break/>3D-printed.</td>
<td valign="top" align="left">Rectangular 10&#x2009;&#x00D7;&#x2009;10&#x2009;&#x00D7;&#x2009;2&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic> sc5314/ATCC MYA-2876</td>
<td valign="top" align="left">Colony-forming units (cfu/ml)</td>
<td valign="top" align="left">Fabrication method</td>
<td valign="top" align="left">Highest biofilm formation and adhesion was reported with 3D-printed resin in comparison to different resins.</td>
</tr>
<tr>
<td valign="top" align="left">Silva et al., 2023 (<xref ref-type="bibr" rid="B35">35</xref>)</td>
<td valign="top" align="left">PMMA<break/>3D-printed</td>
<td valign="top" align="left">Disc-shaped 15&#x2009;&#x00D7;&#x2009;3&#x2005;mm</td>
<td valign="top" align="left"><italic>C. albicans</italic> (SC5314)</td>
<td valign="top" align="left">Colony forming units count (CFU/mL), (ii) cellular metabolism (XTT assay), (iii) fluorescence and thickness of biofilm layers (confocal laser scanning microscopy)</td>
<td valign="top" align="left">Fabrication method</td>
<td valign="top" align="left">Denture base resin type affect <italic>C. albicans</italic> adhesion and colonization and 3D printed resins showed high tendency for <italic>C. albicans</italic> adhesion.</td>
</tr>
<tr>
<td valign="top" align="left">Osman et al., 2023 (<xref ref-type="bibr" rid="B36">36</xref>)</td>
<td valign="top" align="left">PMMA CAD-CAM milled<break/>3D-printed</td>
<td valign="top" align="left">Curved part of the palatal of maxillary denture</td>
<td valign="top" align="left"><italic>C. albicans</italic> (ATCC 10231)</td>
<td valign="top" align="left">Field emission scanning electron microscopy (FESEM)<break/>XTT assay was used for the quantification</td>
<td valign="top" align="left">Fabrication method</td>
<td valign="top" align="left">3D-printing technology results in increased candida adhesion and the roughest surface topography of maxillary resin denture base as compared to conventional flask compression and CAD/CAM milling techniques</td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<fn id="table-fn1"><p>HP, heat polymerized acrylic resin; AP, auto polymerized acrylic resin; CAD-CAM, computer-aided-design-computer-aided-manufacture; PMMA, polymethylmethacrylate; NS, not stated.</p></fn>
</table-wrap-foot>
</table-wrap>
</sec>
<sec id="s2f"><label>2.6</label><title>Quality assessment</title>
<p>According to the method and criteria detailed in previous studies (<xref ref-type="bibr" rid="B37">37</xref>&#x2013;<xref ref-type="bibr" rid="B39">39</xref>), the included studied were investigated for risk of bias (<xref ref-type="table" rid="T4">Table&#x00A0;4</xref>) for study quality assessment. Two independent authors screened included studies using the risk of bias tool guidelines (adapted and modified from Cochrane risk of bias tool) (<xref ref-type="bibr" rid="B37">37</xref>&#x2013;<xref ref-type="bibr" rid="B39">39</xref>).</p>
<table-wrap id="T4" position="float"><label>Table 4</label>
<caption><p>Quality assessment and risk of bias considering aspects reported in material and methods section (risk of bias tool (adapted and modified from cochrane risk of bias tool).</p></caption>
<table frame="hsides" rules="groups">
<colgroup>
<col align="left"/>
<col align="center"/>
<col align="center"/>
<col align="center"/>
<col align="center"/>
<col align="center"/>
<col align="center"/>
</colgroup>
<thead>
<tr>
<th valign="top" align="left">Author/year</th>
<th valign="top" align="center">Allocation concealment</th>
<th valign="top" align="center">Sample size</th>
<th valign="top" align="center">Blinding</th>
<th valign="top" align="center">Assessment method</th>
<th valign="top" align="center">Selective outcome reporting</th>
<th valign="top" align="center">Risk of bias</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top" align="left">Al-Fouzan et al., 2017 (<xref ref-type="bibr" rid="B22">22</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Murat Et al., 2019 (<xref ref-type="bibr" rid="B23">23</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Di Fiore et al., 2021 (<xref ref-type="bibr" rid="B24">24</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">1</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Meirowitz et al., 2021 (<xref ref-type="bibr" rid="B25">25</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Shim et al., 2020 (<xref ref-type="bibr" rid="B26">26</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Li et al., 2022 (<xref ref-type="bibr" rid="B27">27</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">1</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Low</td>
</tr>
<tr>
<td valign="top" align="left">Totu et al., 2017 (<xref ref-type="bibr" rid="B28">28</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Jeon et al., 2022 (<xref ref-type="bibr" rid="B29">29</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Jeon et al., 2022b (<xref ref-type="bibr" rid="B30">30</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Freitas et al., 2022 (<xref ref-type="bibr" rid="B31">31</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Barros et al., 2023 (<xref ref-type="bibr" rid="B32">32</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Li et al., 2023 (<xref ref-type="bibr" rid="B33">33</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">1</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Low</td>
</tr>
<tr>
<td valign="top" align="left">Koujan et al., 2023 (<xref ref-type="bibr" rid="B34">34</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
<tr>
<td valign="top" align="left">Silva et al., 2023 (<xref ref-type="bibr" rid="B35">35</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">1</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Low</td>
</tr>
<tr>
<td valign="top" align="left">Osman et al., 2023 (<xref ref-type="bibr" rid="B36">36</xref>)</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">2</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">0</td>
<td valign="top" align="left">Moderate</td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<fn id="table-fn2"><p>Score was calculated according to following criteria: clearly described (zero), insufficient or ambiguous (1), undisclosed a particular setting (2).</p></fn>
<fn id="table-fn3"><p>Calculating overall score per study and study quality as follow: Studies obtaining an overall score of 0&#x2013;3 low risk (0&#x2013;3), moderate risk (4&#x2013;7), high risk (8&#x2013;10) had.</p></fn>
</table-wrap-foot>
</table-wrap>
</sec>
</sec>
<sec id="s3" sec-type="results"><label>3</label><title>Results</title>
<p>Out of 189, 15 studies (<xref ref-type="bibr" rid="B22">22</xref>&#x2013;<xref ref-type="bibr" rid="B36">36</xref>) investigated the effect of microbial adhesion on CAD-CAM milled and 3D printed denture base resins. Two studies compared CAD-CAM milled resins to conventional denture base resins (<xref ref-type="bibr" rid="B22">22</xref>, <xref ref-type="bibr" rid="B23">23</xref>), and 5 studies compared CAD-CAM milled and 3D printed resins with conventional denture base resins (<xref ref-type="bibr" rid="B24">24</xref>, <xref ref-type="bibr" rid="B25">25</xref>, <xref ref-type="bibr" rid="B31">31</xref>, <xref ref-type="bibr" rid="B34">34</xref>, <xref ref-type="bibr" rid="B36">36</xref>). Five studies investigated microbial adhesion to 3D printed resins (<xref ref-type="bibr" rid="B26">26</xref>&#x2013;<xref ref-type="bibr" rid="B30">30</xref>); two studies investigated the effect of printing technology and printing orientation (<xref ref-type="bibr" rid="B26">26</xref>, <xref ref-type="bibr" rid="B27">27</xref>), while three studies investigated 3D printed dentur base resins modified with TiO<sub>2</sub> nanoparticles (<xref ref-type="bibr" rid="B28">28</xref>) and Phytoncide oil A&#x0026;B (<xref ref-type="bibr" rid="B29">29</xref>, <xref ref-type="bibr" rid="B30">30</xref>). <italic>C. albicans</italic> is most frequently investigated in all included studies except two studies included <italic>Candida scotti</italic> (<xref ref-type="bibr" rid="B28">28</xref>), and <italic>Lactobacillus salivarius</italic>, <italic>Streptococcus mutans</italic> (<xref ref-type="bibr" rid="B24">24</xref>). Different microbial assay methods were included; colony-forming units (CFU) (<xref ref-type="bibr" rid="B22">22</xref>, <xref ref-type="bibr" rid="B24">24</xref>, <xref ref-type="bibr" rid="B29">29</xref>, <xref ref-type="bibr" rid="B31">31</xref>, <xref ref-type="bibr" rid="B32">32</xref>, <xref ref-type="bibr" rid="B34">34</xref>, <xref ref-type="bibr" rid="B35">35</xref>), microscopic evaluation (Mean cell/field) (<xref ref-type="bibr" rid="B23">23</xref>, <xref ref-type="bibr" rid="B25">25</xref>, <xref ref-type="bibr" rid="B29">29</xref>), quantified using scanning electron microscopy (<xref ref-type="bibr" rid="B25">25</xref>, <xref ref-type="bibr" rid="B26">26</xref>, <xref ref-type="bibr" rid="B30">30</xref>, <xref ref-type="bibr" rid="B33">33</xref>, <xref ref-type="bibr" rid="B36">36</xref>), Relative metabolic activity (<xref ref-type="bibr" rid="B27">27</xref>), and Dehydrogenase assays (<xref ref-type="bibr" rid="B28">28</xref>).</p>
<p><xref ref-type="table" rid="T4">Table&#x00A0;4</xref> summarizes the quality assessment of the included studies. Out of the included studies, twelv studies revealed a moderate risk of bias, low risk was noted in three studies. Primarily the risk was attributed to the lack of allocation concealment, sample size calculation and examiner blinding.</p>
<p>Despite differences in denture base resin type and microbial assay between the included studies, CAD-CAM milled denture base resins demonstrated the lowest microbial adhesion compared to conventional, while 3D printed dentures demonstrated the highest microbial adhesion (<xref ref-type="bibr" rid="B31">31</xref>). For 3D printed resins, the proportions of microbial adhesion were highest at 0 degrees and lowest at 90 degrees (<xref ref-type="bibr" rid="B25">25</xref>). While the combined effect of printing technology (SLA and DLP) and printing orientation had no effect on microbial adherence (<xref ref-type="bibr" rid="B27">27</xref>). On the level of 3D printed resin modifications, both additives TiO<sub>2</sub> nanoparticles (<xref ref-type="bibr" rid="B28">28</xref>), and Phytoncide oil A&#x0026;B (<xref ref-type="bibr" rid="B29">29</xref>, <xref ref-type="bibr" rid="B30">30</xref>) decreased the microbial adhesion.</p>
</sec>
<sec id="s4" sec-type="discussion"><label>4</label><title>Discussion</title>
<p>In subtractive method, the fabrication of denture base from prefabricated PMMA discs improved the mechanical behavior as well as the surface properties when compared to conventional heat polymerized denture base (<xref ref-type="bibr" rid="B4">4</xref>). As a result of the good surface properties of CAD-CAM milled denture base resins, less microbial adherence is expected. This was confirmed by all authors (<xref ref-type="bibr" rid="B22">22</xref>&#x2013;<xref ref-type="bibr" rid="B36">36</xref>), who reported that milled denture base resins had lower <italic>C. albicans</italic> adhesion f and reduce the occurrence of DS in long-term denture use. Di Fiore et al. (<xref ref-type="bibr" rid="B24">24</xref>) used scanning electron microscope (SEM) to examine the surface topography of each material and found that the conventional ones had multiple grooves and deep scratches with a porous surface, whereas CAD-CAM milled had a smooth surface with fewer scratches.</p>
<p>3D printed resins have low surface properties when compared to milled and conventional ones. In between the included studies, two studies (<xref ref-type="bibr" rid="B24">24</xref>, <xref ref-type="bibr" rid="B25">25</xref>) compared the <italic>C. albicans</italic> adhesion of 3D printed with CAD-CAM milled denture base resins and conventional and found that 3D printed resins exhibited significantly more microbial adhesion. This was primarily due to the nature of the printing technology; layer-by-layer object building and this layering technique resulted in stepwise edges on the specimens&#x0027; surfaces (<xref ref-type="bibr" rid="B24">24</xref>, <xref ref-type="bibr" rid="B25">25</xref>). Based on SEM analysis of specimens&#x0027; surface by Di Fiore et al. (<xref ref-type="bibr" rid="B24">24</xref>), 3D printed resins showed more surface irregularities, multiple dots, and serrations that probably attributed to the layering of printed objects and the polymerization method (<xref ref-type="bibr" rid="B24">24</xref>). Previous researches (<xref ref-type="bibr" rid="B4">4</xref>, <xref ref-type="bibr" rid="B31">31</xref>) assessed the surface roughness of 3D printed resins and found rougher surfaces than conventional even when the printing parameters were changed. While another study found no difference between CAD-CAM milled and 3D printed denture base resins in terms of surface roughness (<xref ref-type="bibr" rid="B5">5</xref>, <xref ref-type="bibr" rid="B31">31</xref>).</p>
<p>The printing technology was thought to be a factor influencing the properties of 3D printed objects (<xref ref-type="bibr" rid="B15">15</xref>). SLA and DLP are the most commonly used technologies for fabricating denture bases (<xref ref-type="bibr" rid="B40">40</xref>). Surface roughness differences were reported between the two technologies (<xref ref-type="bibr" rid="B27">27</xref>), with SLA exhibiting irregular surfaces and DLP printed specimens exhibiting clear and regular texture. However, Li et al. found no difference in <italic>C. albicans</italic> adhesion between SLA and DLP technology (<xref ref-type="bibr" rid="B27">27</xref>).</p>
<p>Another factor was the printing orientation (<xref ref-type="bibr" rid="B26">26</xref>, <xref ref-type="bibr" rid="B27">27</xref>), which could result in different surface patterns depending on the printing layer directions (<xref ref-type="bibr" rid="B27">27</xref>). According to Li et al. (<xref ref-type="bibr" rid="B33">33</xref>), printing orientation has a significant impact on Ra values regardless of printing technology (<xref ref-type="bibr" rid="B25">25</xref>, <xref ref-type="bibr" rid="B41">41</xref>). Some surface features were observed with different printing angles (45&#x00B0; and 90&#x00B0;) and exhibited a ladder-like surface structure (<xref ref-type="bibr" rid="B33">33</xref>). Roughness changes in relation to building direction were caused by the height of step edges and the stepwise connection between printed layers (<xref ref-type="bibr" rid="B26">26</xref>). Li et al. (<xref ref-type="bibr" rid="B33">33</xref>) investigated the same orientations and two AM methods (SLA and DLP) and found no significant differences in <italic>C. albicans</italic> adhesion. When the printing orientation and post-curing time were varied, Al-Dulaijan et al. found no change in the surface roughness of 3D printed resins (<xref ref-type="bibr" rid="B42">42</xref>). With changing printing orientation, the layer direction is changed and affected the specimens&#x0027; surface, 0-degree is expected to be smooth as the surface of specimens formed by the last printed layer (<xref ref-type="bibr" rid="B26">26</xref>). However, Shim et al. (<xref ref-type="bibr" rid="B26">26</xref>), printed specimens with different orientations (0-, 45-, and 90-degree) and evaluated the microbial adhesion and found that 0-degree showed the highest proportion. This conflict (smooth surface with more <italic>Candida</italic> adherence) could be clarified based on the surface wettability of 0-egree showed the highest hydrophilicity value according to Shim et al. (<xref ref-type="bibr" rid="B26">26</xref>). These findings support the hypothesis that the microbial adhesion of 3D printed resins is primarily due to surface features and wettability (<xref ref-type="bibr" rid="B1">1</xref>). Surface coatings of conventional PMMA denture base resins were suggested as a possible method to create a smooth surface denture base to overcome the low surface properties (<xref ref-type="bibr" rid="B43">43</xref>). However, this has not been investigated as of yet, so further research is advised.</p>
<p>Incorporating antifungal agents within the 3D printed fluid resin was another method for improving antimicrobial activity (<xref ref-type="bibr" rid="B28">28</xref>, <xref ref-type="bibr" rid="B30">30</xref>). Two antimicrobial agents, TiO<sub>2</sub> nanoparticles (<xref ref-type="bibr" rid="B28">28</xref>) and Phytoncide oil A&#x0026;B (<xref ref-type="bibr" rid="B29">29</xref>, <xref ref-type="bibr" rid="B30">30</xref>), were successfully added as antimicrobial agents to 3D printed resins. TiO<sub>2</sub>&#x0027;s antimicrobial effect is primarily due to its photocatalytic effect, in which UV irradiation results in oxidization decomposition (<xref ref-type="bibr" rid="B44">44</xref>, <xref ref-type="bibr" rid="B45">45</xref>). By coordinating electron-donating groups, this effect resulted in the deactivation of cellular enzymes. This process ended by gabs in cell allowing higher permeability cell death (<xref ref-type="bibr" rid="B44">44</xref>). As phytoncide concentrations increased, the viability of fungal cells and optical density decreased, consequently increasing the number of atypical cells morphologically (<xref ref-type="bibr" rid="B45">45</xref>). In addition to having antimicrobial effect, phytoncide-filled microcapsules; the microbial adhesion, attachment, and growth were inhibited significantly when incorporated into 3D printed resins regardless of pH value (<xref ref-type="bibr" rid="B29">29</xref>, <xref ref-type="bibr" rid="B30">30</xref>). The effect of phytoncide-filled microcapsule concentrations was found to significantly reduce <italic>C. albicans</italic> adhesion with increasing concentrations. In addition, the surface roughness increased with concentration but had no effect on <italic>C. albicans</italic> adhesion, confirming the antifungal activity of 3D-printed resin containing phytoncide-filled microcapsules (<xref ref-type="bibr" rid="B29">29</xref>, <xref ref-type="bibr" rid="B30">30</xref>). As a result of the antifungal activities being reported and demonstrating significantly less candida adhesion when compared to the unmodified one. Both studies (<xref ref-type="bibr" rid="B29">29</xref>, <xref ref-type="bibr" rid="B30">30</xref>) recommended using the introduced modified-3D printed resins for denture base fabrication.</p>
<p>Although modified 3D printed resins were found to have a positive antifungal effect, the lack of comparison with conventional or CAD-CAM milled denture base resins was considered a limitation in both studies (not used as control). In light of the findings of both studies, additional research on antimicrobial-modified 3D printed resins in comparison with conventional and CAD-CAM denture base resins is recommended rather than a comparison with the unmodified one. This was due to the fact that the modification effect was good, but still highly significant when compared to the conventional method. Moreover, microbial adhesion and related surface properties testing in terms of hydrophobicity are required (<xref ref-type="bibr" rid="B1">1</xref>).</p>
<p>Based on the review findings, CAD-CAM milled denture base resins were found to be the most appropriate materials for denture base fabrication with low microbial adhesion. 3D printed resins were more susceptible to microbial adhesion and require additional research with different printing technologies, resin modifications, or printed object surface modifications before clinical recommendations.</p>
<p>Although the importance of the subject in which this systematic review was able to compare the most recent literatures on microbial adhesion to different denture base resins, nevertheless, the included articles were limited to <italic>in vitro</italic> studies reducing the scientific evidence of study point. In addition to other limitations due to the small number of studies included, as well as differences in resin type, fabrication method, variables investigated, and microbial assessment methods. All of these constraints made it difficult to reach a clear conclusion based on the study objective. As a result, a future systematic review was suggested.</p>
</sec>
<sec id="s5" sec-type="conclusions"><label>5</label><title>Conclusions</title>
<p>CAD-CAM milled denture base resin had lower microbial adhesion. When compared to conventional heat polymerized and CAD/CAM milled denture base resins, 3D printed resins have a high tendency for microbial adhesion due to their poor surface properties. The addition of antimicrobial agents to 3D printed resins reduced microbial adhesion. However, more research is needed to prove the effects of these additives when combined with different printing parameters.</p>
</sec>
</body>
<back>
<sec id="s6" sec-type="data-availability"><title>Data availability statement</title>
<p>The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.</p>
</sec>
<sec id="s7" sec-type="author-contributions"><title>Author contributions</title>
<p>FKA: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing &#x2013; original draft, Writing &#x2013; review &#x0026; editing. MMG: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing &#x2013; original draft, Writing &#x2013; review &#x0026; editing.</p>
</sec>
<sec id="s8" sec-type="funding-information"><title>Funding</title>
<p>The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.</p>
</sec>
<sec id="s9" sec-type="COI-statement"><title>Conflict of interest</title>
<p>The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.</p>
</sec>
<sec id="s10" sec-type="disclaimer"><title>Publisher&#x0027;s note</title>
<p>All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.</p>
</sec>
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