2.3.137-140

Review article Annals and Essences of Dentistry

Vol. - II Issue 3 July Sept. 2010 137

XEROSTOMIA: DENTAL IMPLICATIONS AND MANAGEMENT.

*Ramandeep Dugal

*Professor, Department of Prosthodontics, MA Rangoonwala Dental College, Pune

ABSTRACTXerorstomia or dry mouth is common among older adults and may be caused by systemic diseases,medications and head and neck radiotherapy. Individuals with Xerostomia complain of problems withmastication, phonetics, deglutition and wearing dentures. Lack of saliva may predispose one to oral infectionssuch as Candidiasis and increased risk of dental caries. Dentists should be able to diagnose this condition andadminister appropriate treatment to provide acceptable level of comfort and function to their patients.

KEYWORDS: Xerostomia, Saliva, Dental implications, Management.

INTRODUCTION:Xerostomia is defined as dry mouth resulting from

reduced or absent salivary flow. Saliva plays acritical role in the preservation of oropharyngealhealth and persistent dry mouth and salivarydysfunction can impair a persons quality of life.Xerostomia is a common complaint among olderadults and according to a study 30 percent ofpopulation aged 65 and above experience thisdisorder1. Though salivary functions remain intact inhealthy older people yet a plethora of systemicdiseases, medications and head and neckradiotherapy cause Xerostomia particularly in elderlypatients2. With increase in longevity, we have amuch larger population of older adults and thereforeit becomes even more important to understandproblems associated with dry mouth and theirtreatment to improve the patients oropharyngealhealth and quality of life.

Common causes of XerostomiaXerostomia is a common complaint associated withseveral conditions, which include side effects of widevariety of medications3,4, therapeutic radiation tohead and neck, systemic diseases and diseasesinvolving the salivary glands. Common causes aresummarized the in the table below (Table 1)

Evidence suggests that salivary glands arevulnerable to deleterious effects of all theseconditions in the elderly people which contribute toincreased prevalence of salivary problems with age.

Clinical Manifestations of Xerostomia

Saliva is essential for the preservation oforopharyngeal health, and it serves many functionsin the oral and gastrointestinal environment. Salivaaids in swallowing, oral cleansing, speech,digestion and taste. When salivary hypofunctionand xerostomia occur, transient and permanent oraland extraoral disorders can develop2. Xerostomia isoften a contributing factor for both minor andserious health problems. It can affect nutrition aswell as psychological health. Individuals withXerostomia complain of dry mouth and problemswith eating, speaking and swallowing. There is oralburning or soreness and a sensation loss of oraltered taste (Dysgeusia)5. Another manifestation isincreased need to drink water while swallowing anddry crumbly foods are difficult to swallow.

Dental Implications Patients with Xerostomia experience various

oral symptoms that are as follows: Increased susceptibility to periodontal disease:

Xerostomia decreases the oral pH andincreases the development of plaque and dentalcaries. Caries is a frequently occurring dentalproblem in such patients and this process isaccelerated owing to reduction of salivary flowand inability to clear the food from oral cavityparticularly sugary and acidic foods5. Thedevelopments of rampant caries particularly atcervical area have been observed have beenobserved within few weeks after radiationtherapy to head neck10.

Review articles Annals and Essences of Dentistry


Reduced denture retention and generalizeddenture intolerance. Decreased salivary

lubrication makes denture use unpleasant andpainful and chronic denture movement results in irritation and ulceration of already compromised

mucosa9. Decreased buffering capacity in the oral cavity

with increased risk of opportunistic infections.Reduction of saliva predisposes the patient toan over growth of the fungus C. albicans11. Thismay be augmented by use of denture,bysmoking or by presence of diabetes12. Increased oral sensitivity, soft tissue erythema,

burning mouth and intolerance to wearing ofdenture. Demineralization of tooth tissue, rapidly

progressive dental caries and dental attrition6.

DiagnosisDiagnosis can be obtained from patients history andexamination of oral cavity and/or sialometry i.emeasuring the flow rate of saliva13. Four clinicalmeasures, when concurrently identified onexamination, have been shown to be reliablepredictors of salivary gland hypofunction: dryness ofthe lips, dryness of the buccal mucosa, absence ofsaliva production during gland palpation, anddecayed/missing/filled teeth (i.e, DMFT) score.14

Sialography may be used to identify salivary glandstones and masses. Salivary scintigraphy can beused in assessing salivary gland function. Minorsalivary gland biopsy is used for diagnosis ofSjgren's syndrome, HIV salivary gland disease,sarcoidosis and amyloidosis. Biopsy of majorsalivary glands is an option when malignancy issuspected.

Management of XerostomiaManagement should include identification of theunderlying cause. Substances and habits thatpotentiate oral dryness, such as smoking, alcohol,and caffeine should be avoided.When xerogenic drugs are implicated, alternativemedication, dose reduction, or drug withdrawalshould be considered. Another option is to alternatepharmaceutical regimens: nocturnal xerostomia canbe minimized by taking the xerogenic drug duringthe day time when salivary production is optimal9.

Caries prevention: A low sugar diet and daily useof topical fluoride, placement of sealants andantimicrobial mouth rinses are critical to preventdental caries15. Patients should be instructed to

drink plenty of fluids especially while eating dry andrough foods, but should avoid sugar containing

juices and soft drinks. Topical fluorides may beuseful when there is increased incidence of coronalcaries, root caries or bothand may be helpful inprevention of caries as well as reversal ofdecalcification. Supplements containing sodium

Table 1: Common causes of Xerostomia

Medications Antihistamines Antidepressants and

antipsychotics Antihypertensives Antianxiety agents Diuretics Antiparkinsonism drugs Antiematics Bronchodilators Sedatives

Diseasesaffecting thesalivary glands

Sjgren's syndrome Sarcoidosis Amyloidosis

SystemicDiseases

Diabetes HIV infections Chronic graft-vs-host

disease after allogenicbone marrow transplant Emotional Stress and

mental depression

RadiationTherapy (Causespermanentchanges)

Radiation therapy tohead and neck region forSquamous cell cancersof oral cavity,oropharynx, nasopharynx and sinuses Brain tumours Tumours of salivary

gland

Chemotherapy(causestemporarychanges)



fluoride, acidulated phosphate fluoride or sodiummonofluorophosphate are available for professionalapplication and for home use. These products are

available in form of gels and rinses. Use of fluoridecontaining varnishes that provide prolongedfluoride exposure have also been advocated. Incase of active caries, caries should be controlledand lesions should be properly restored.

Saliva stimulation and substitution: For patientswith remaining viable salivary gland tissue, salivarystimulation may be helpful. Sugar free chewinggum,candies and mints can be used for stimulationof saliva. Pilocarpine hydrocholoride and Cevimilinehydrochloride are commonly used drugs for salivarystimulation and produce clinically significantincrease in salivary flow in xerostomic patients16.These drugs are contraindicated in patients withuncontrolled asthma, narrow angle glaucoma oriritis. Varieties of salivary substitutes are availableand are effective in decreasing oral dryness. Theyare useful for patients in whom saliva can not bestimulated.

Treatment of oral candidiasis: Oral candidiasis isa frequent complication in xerostomic patients andis treated with topical antifungal agents in the formof oral rinses, ointments and troches. Systemicantifungal therapy is indicated in cases of activeinfection or in immunocompromised patients.

Prosthodontic Management of Xerostomiapatients

Fixed prosthothesis.In the dry oral environment,fixed non tissue bearing prosthesis are preferredwhere indicated. Fixed partial dentures shouldhave full coverage retainers and easily cleanedpontics and connectors. The margins of retainersshould be supragingival.

Removable partial denture In case of partiallyedentulous patients using removable prosthesisspecial attention should be given to residual teethand periodontal tissues. The use of gingivallyapproaching clasps should be avoided as it tendsto catch on the cheeks. Whenever possible toothsupported denture with minimal tissue coverageshould be used. Metal denture bases arepreferred due to their better wettability.

Complete denture treatment When consideringcomplete denture treatment for xerostomic patient,close attention should be given to clinical andlaboratory procedures aimed at optimizing dentureretention and stability. Dentures incorporatingmetal bases may exhibit improved accuracy of fitand effective wetting contributing to betterretention17,18. Metal based prosthesis are alsoeasier to clean and have less plaqueaccumulation. Soft denture liners may be used toimprove comfort. Dentures adhesives can be usedto augment retention in Xerostomic patients. Inaddition to improved retention and stability, use ofa well hydrated denture adhesive providescushioning and lubricating effect19. Denturepatients are more prone to Candida albicansinfections. Therefore frequent recalls arenecessary and if infection is present systemic anti-fungal treatment is required. Dentures supportingtissues can be treated locally with antifungalagents by coating the tissue surface of the dentureprior to placement. The use of dental implants tosupport both fixed and removable prosthesis is anow a routine treatment option for restoration ofedentulous and partially edentulous patients.Patients wearing implant supported denturesreport improved oral comfort and function whencompared with conventional, mucosa-supportedprosthesis6.

Regular review Patients with xerostomia should bemade to understand the importance of regular recallvisits every three months to prevent uncontrolledcaries and denture patients should be reviewed atregular intervals to prevent candida infections andproblems associated with denture wear inxerostomic patients.

CONCLUSIONXerostomia is a common problem encountered inolder adults and if not recognized and treated canhave significant effect on patients quality of life.Dental practitioner should be able to diagnose drymouth disorder in their elderly patients and providepreventive and definitive treatment to achieveacceptable levels of comfort and function.

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5. James Guggenheimer and Paul A. Moore.Xerostomia Etiology, recognition and treatment. JAM Dent Assoc 2003 Vol. 134,No.1,61-69.

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11. Samaranayake LP. Host factors and oralcandidosis. In: Samaranayake LP, MacFarlane TW,eds. Oral candidosis. London: Wright; 1990:66103.

12. Guggenheimer J, Moore PA, Rossie K, et al.Insulin-dependent diabetes mellitus and oral softtissue pathologies, part II: prevalence andcharacteristics of Candida and candidal lesions.Oral Surg Oral Med Oral Pathol Oral Radiol Endod2000;89:5706.

13. Deborah Greenspan. Xerostomia: Diagnosis andmanagement. Oncology 1996; 10(Suppl):7-11.

14. Navazesh M, Christensen C, Brightman V. Clinicalcriteria for the diagnosis of salivary glandhypofunction. J Dent Res. 1992;71:1363-1369.

15. Ship JA. Diagnosing, managing, and preventingsalivary gland disorders. Oral Dis 2002;8(2):7789.

16. Niedermeier W, Matthaeus C, Meyer C, Staar S,Muller RP, Schulze HJ. Radiation-inducedhyposalivation and its treatment with oralpilocarpine. Oral Surg Oral Med Oral Pathol OralRadiol Endod 1998;86:541-9.

17. Lloyd PM. Complete-denture therapy for thegeriatric patient. Dent Clin North Am. 1996;40:239-254.

18. Hummel SK, Marker VA, Buschang P, et al. A pilotstudy to evaluate different palate materials formaxillary complete dentures with xerostomicpatients. J Prosthodont. 1999;8:10-17.

19. Grasso JE, Rendell J, Gay T. Effect of dentureadhesive on the retention and stability of maxillarydentures. J Prosthet Dent. 1994;72:399-405.

Corresponding AuthorDr. Ramandeep Dugal MDS

ProfessorDepartment of Prosthodontics

MA Rangoonwala Dental College,Pune

Phone: 02032914104Email: [email protected]

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2.3.137-140