Indian J Stomatol 2011;2(4):263-66
Management of Xerostomia and Hyposalivation in Complete Denture Patients
1
GS Chandu , MN Hombesh
2
Abstract: Xerostomia is a clinical condition caused by a decrease in the production of saliva. Xerostomia is a relatively common complaint that can make the wearing of the dentures extremely discomfortable for the affected edentulous patients. To overcome this problem, various techniques have been proposed including the preventive measures, management of symptoms, measures to increase the salivary flow, use of saliva substitutes and reservoir dentures. The article provides an update on the management of xerostomia in complete denture patients. Keywords: Xerostomia, hyposalivation, salivary substitute, complete denture. Introduction Xerostomia is defined as the dry mouth resulting from the reduced or absent salivary flow. It is a clinical condition caused by a decrease in the production of saliva which may present itself as a local symptom, as part of a systemic disease such as Sjogren's syndrome, diabetes, alcoholism or as side effects of medications or following therapeutic radiation to the head and neck regions. Xerostomia is a common complaint among the elderly people and according to a study 30% of the people aged beyond 65 years experience this disorder. Use of medication and age are significant risk factors for dental patients reporting xerostomia.1 Edentulous patients suffering from xerostomia may complain of not only dry mouth, but also difficulty in normal functions like eating, speaking, swallowing, etc. The other symptoms include cracking at the corners of the mouth; a burning sensation on the tongue associated with the fissuring of the tongue; and alteration of the taste. Extreme discomfort in wearing dentures is a common complaint.1,2 Saliva plays an important role in retention and comfort of the removable prosthesis. In denture wearing population the salivary wetting mechanics are necessary to create adhesion, cohesion and surface tension that helps in the increased retention of the complete denture. Adhesion is the bond created by saliva between the oral mucosal epithelium and the denture base. Cohesion is the bonding between saliva components that leads to greater retention of prostheses. Surface tension is the denture's ability to resist separation from tissues and is related closely to the fit of the prosthesis. An intimate fit of denture bases to supporting tissues and the presence of adequate border seals will provide optimal denture function, provided that saliva is adequate in amount, flow and consistency. Saliva allows for the formation of a vacuum pressure on the seating of dentures and contributes significantly to denture retention and the wearer's satisfaction with the prosthesis. Dentures can dislodge during function and the presence of adequate saliva and swallowing allows for repeated seating of the prosthesis and subsequent retention and denture stabilization. Adhesion, cohesion and surface tension are inter3,4 related and they all depend on saliva.
Absence of saliva in the interface of denture and mucosa can cause denture sores because of the lack of lubrication and denture retention. Lack of denture stability and retention can cause social embarrassment to a patient if dentures dislodge during the function. Therefore the xerostomia and salivary hypofunction can have a devastating effect on the psychology of the patient.5 The purpose of this article is to discuss the management of xerostomia and hyposalivation in complete denture patients. Different strategies in the management of xerostomic patients wearing complete dentures Depending upon the cause, a variety of treatment options is available to the clinician. In medication induced xerostomia, liaison with a patient's general medical practitioner to discuss the timing, dosage or a change in the medication may reduce the severity of the disease. Alternatively, gustatory stimulation of the salivary glands by mastication of the sugar free chewing gums or lozenges is helpful.6 In severe xerostomia cases, saliva substitutes or salivary stimulants may be used. Soft denture liners can also be used to minimize patient discomfort. Often a combination of treatment may be required.5 7
General measures (etiological treatment) Among the general measures to be taken into account when treating patients with dry mouth, consideration should first focus on the control of any systemic disorders that may be responsible for the oral problem. The most important examples in this case are Sjögren's syndrome and the side effects of high-dose radiotherapy in head and neck cancer patients. Aminofostine, a selective cytoprotector that acts upon the salivary glands, kidneys, liver, heart or bone marrow can be used to limit the undesirable effects of radiotherapy for head and neck cancer. This drug is an organic thiophosphate that undergoes dephosphorylation mediated by alkaline phosphatase to yield the active thiol metabolite, which eliminates free radicals in healthy cells. The drug has side effects such as nausea, vomiting and hypotension and hypocalcemia may also result. In these patients with dry mouth it is essential to substitute,
1 Professor, Deptt. of Prosthodontics, Mansarovar Dental College and Hospital, Bhopal, 2Reader, Deptt. of Prosthodontics, SJM Dental college and Hospital, Chitradurga, India. Correspondence: Dr. Chandu GS, email: chandugs @gmail.com
263
Indian J Stomatol 2011;2(4):263-66 Management of symptoms8 Symptoms
Management
Dry mouth
Improve oral hygiene/ saliva substitutes
Difficulty with speech
Chlorhexidine (CHX) gel or mouth rinse
Difficulty with swallowing
Avoid sugar- sweetened drinks/ confectionery
Disturbed taste sensations
Suck chips of ice
Increased caries rate and periodontal disease
Restoration of caries, fluoride mouth rinse and CHX mouth rinse
Oral infections
Prescribe as appropriate
Treatment of oral conditions7 Dental caries
Restorative therapy, topical fluoride application
Oral Candidiasis
CHX 0.12%: rinse, swish, and spit 10 ml twice daily Nystatin/triamcinolone ointment for angular cheilitis: apply topically 4 times daily Clotrimazole troches: 10mg dissolved orally 4-5 times daily for 10 days Systemic therapy for immunocompromised patients
Denture antifungal treatment
Soaking of denture for 30 minutes daily in CHX or 1% sodium hypochlorite.
Bacterial infections
Systemic antibiotics for 7–10 days
Ill or poor fitting prostheses
Denture adjustment Hard and soft reline Use of denture adhesives Implant-borne prostheses
reduce or suppress any xerostomizing medication. The physician controlling the patient should be consulted on this point. Likewise, some patients may be on diets that induce a degree of dehydration, such as low-salt diets in hypertensive individuals, while others may be using antidiuretic drugs. In these cases adequate patient hydration must be ensured, with the ingestion of at least two liters of liquid daily. It is also important to avoid irritants such as coffee, alcohol or tobacco smoking. Psychopathological factors are increasingly frequent causes of xerostomia, particularly chronic anxiety and stress. These disorders must be evaluated and treated. In this sense, benzodiazepines can be prescribed, such as ketazolam 15-30mg after dinner, followed by gradual (not sudden) dose reduction. Preventive measures Preventive care should be addressed next. Extra measures should be instituted to prevent oral complications from low salivary output. This starts with frequent dental and oral
264
evaluations, with examinations every 4-6 months and radio- graphs performed annually. To prevent dental caries in case of single complete denture or overdenture, meticulous oral hygiene, a low-sugar diet, and regular use of topical fluori- de are recommended. Daily use of neutral pH sodium fluoride is the most effective means of preventing rampant hyposalivation-induced caries. Fluorides and reminera- lizing solutions are available as varnishes, dentifrices, gels, and rinses, which can be used with or without applicator trays. The specific preventive fluoride regimen should be determined by the dentist and patient by considering the extent of salivary gland hypofunction and the caries rate.7 Increase salivary flow or salivary stimulation (sialogogues)9 In patients with dry mouth it is important to determine whether functional salivary gland parenchyma remaining can be stimulated mechanically or chemically. Stimulation can be achieved through simple measures such as more
Indian J Stomatol 2011;2(4):263-66 frequent meals, the ingestion of lemonade or acid drinks, the dissolving of sugar-free essence candies in the mouth, or the prescription of xylitol chewing gum. It is also possible to administer sialogogues that directly stimulate the salivary glands, such as anetoltritione, pilocarpine and cevimeline and bethanechol. Management of underlying systemic conditions The most common systemic disease is Sjögren’s syndrome, an autoimmune exocrinopathy producing dry eyes and a dry mouth. Other pertinent diseases include rheumatoid arthritis, HIV infection, diabetes, Alzheimer disease and stroke. The most common cause of salivary disorders in elderly people is prescription and nonprescription medications, primarily because of certain drugs' anticholinergic effects. These medications include tricyclic antidepressants, sedatives and tranquilizers, antihistamines, antihypertensive agents, cytotoxic agents, anti parkinsonism agents and antiseizure drugs. Radiation therapy, a common treatment modality for head and neck cancers, causes permanent salivary hypofunction and persistent xerostomia. The xerostomic side effects of medications may be alleviated or reduced by substituting for the problem with medications that have lesser side effects. Moreover, alterations in the timing or dosing schedule of medications, such as avoidance of medication doses at night time when salivary flow is normally at its lowest, may minimize xerostomic effects. Multidisciplinary management of underlying systemic conditions is imperative to reduce oral complications.3 Use of saliva substitutes In patients with extreme or prolonged dry mouth, substances that replace lost salivary function and components can be used. These options include artificial saliva, which humidifies the oral cavity, particularly protecting it from irritative mechanical or chemical factors and infections. Such preparations consist of aqueous solutions containing glycoproteins or mucins, and salivary enzymes such as peroxidase, glucose oxidase or lysozyme. Polymers such as carboxymethyl cellulose have also been used with the aim of protecting the soft tissues, or ions such as calcium and phosphates or fluorides for protecting the hard struct9 ures of the teeth. The artificial saliva can be classified into three groups-8 a) Glycerine and lemon: They are the simplest but, if natural teeth are present, it may also cause erosion, in addition glycerine is astringent and may sting the soft tissues. b) Those based on carboxymethyl cellulose. c) Those based on mucin; mucin based artificial saliva have best properties. Milk can also be recommended as a salivary substitute. Milk appears to have many chemical and physical properties of a good saliva substitute. In addition to moistening and lubricating the oral mucosa, milk is capable of buffering oral acids, reducing enamel solubility and contributing to enamel remineralisation. These properties are attributable to calcium and phosphate content as well as milk phosphoprotiens that adsorb to enamel because of these factors milk is regarded as a good saliva substitute. Some saliva substitutes are based on pig products (bovine/ porcine) and are contraindicated in vegetarians.
Some patients tend to use home remedies such as margarine A water soluble extract of linseed oil has been found to have physical properties similar to glycoprotiens of saliva. Salinum is based on this linseed oil. Few commercially available saliva substitutesA) Luborant: Contains lactose peroxidase which increases oral defense mechanisms. It can be given in any condition giving rise to dry mouth. B) Glandosane (Fresinius): It is indicated in denture wearers only, because pH of glandosane is 5.0 and can cause subsurface demineralization in dentulous patients. C) Saliva orthona (Nycomed): It is an oral spray containing porcine mucin. It is also available as a lozenge. It is unsuitable for certain ethnic group and vegetarians. D) Oral balance/biotene: It is available as mouth rinse, lozenges and toothpaste. It contains several components such as polyglycerol methacrylate, lactoperoxidase and glucose oxidase. It diminishes the sensation of oral dryness and improve oral functions. Biotene can also cause subsurface demineralization. E) Salinum: Based on water soluble extract of linseed oil. F) Salivix pastilles (tablets): acts locally as salivary stimulants. Use of oral lubricating devices In order to permit the wearing of dentures, artificial saliva preprations have been recommended. The major drawback of artificial saliva is that it must be mechanically introduced into the oral cavity by the patient at regular intervals. Patients object to carry a bottle of artificial saliva and would prefer a more convenient saliva delivery system in the form of reservoir dentures or oral lubricating devices.6,10 11 Requirements of oral lubricating devices1.Should provide sustained release of saliva substitutes. 2.Should provide slow release of artificial saliva. 3.Should be easy to use. 4.Should be easy to clean. 5.Should not interfere with normal oral functions. Several authors have recommended many novel approaches to fabricate the reservoir dentures within the available space either in the maxillary denture or in the mandibular denture. Few authors have even recommended 12-14 the incorporation of reservoirs to the existing dentures. Hirvikingas et al., attempted modifications of both dentures but succeeded only with their design for the maxillary denture, which used a gerber attachment to operate the 15 release mechanism for the saliva substitute. Vissink et al., recommended the use of maxillary and or mandibular reservoirs according to the need.16 Discussion Depending on the etiology of the xerostomia, various treatment options are available as mentioned above. However, often the combinations of one or more methods are employed to make the prosthesis successful. The goal in the management of xerostomia is to reduce the suffering from the disease and to make the wearing of the dentures and performing normal oral functions comfortable to the patient. At the same time priority should be given to optimize the retention and stability of the prosthesis. Denture adhesives can be used to increase the retention, use of well
265
Indian J Stomatol 2011;2(4):263-66 hydrated denture adhesives provides the cushioning and lubricating effects. Metal denture bases show higher accuracy of fit and effective wetting contributing to improved retention, also they are easier to clean and have less plaque accumulation. Soft denture linings may be added to increase the comfort. However denture patients with xerostomia are more prone to candida infections and care should be taken to maintain proper oral hygiene. Possible options to fabricate implant supported prosthesis or fully bone anchored prosthesis should be verified. Patients wearing implant supported prosthesis exhibit increased comfort, stability and retention when compared to mucosa supported prosthesis.12 Patients with insufficient saliva benefit from wetting their dentures before placing them in the mouth. Salivary substitutes, artificial saliva and salivary stimulants therefore can be beneficial for the denture-wearing patient in terms of helping with adhesion and cohesion, and subsequently, prosthesis retention. Patients can be advised to spray their prostheses with artificial saliva before denture insertion and before meals. During mealtime, greater intake of liquid and of water in particular, is recommended. Increasing the wetting of the prosthesis enhances retention and stability during function, and this will aid in mastication and swallowing. Intermittent intake of water also can help during speech. Although the use of adhesives in patients with xerostomia and hyposalivation requires additional care, it often is necessary to stabilize a removable prosthesis. 3 Whenever the lubricating devices or reservoir dentures are planned, the nature, size and location of the device, particularly its reservoir, are pivotal features of the lubricating system design, especially when aiming to maintain normal oral functioning. The location of the reservoir should be as unobtrusive as possible whilst containing a useful amount of saliva substitute. In edentulous people, either the palate or the interior of a mandibular complete denture has been used as a reservoir, although cleanability and saliva substitute flow were concerns. In dentate people, the palate is generally the location of choice although anatomical features, especially the width and depth of the palatal vault, are important considerations when determining the size and shape of the reservoir.13 Patients should be instructed to wet their prosthesis before applying adhesive, and a combined use of artificial saliva and denture adhesive appears to be beneficial. There is a dearth of studies examining the use of adhesives and artificial saliva to enhance denture retention and reduce xerostomia in edentulous patients with salivary hypofunction. Furthermore, there is a need for the development of long-lasting materials that will improve patient comfort; increase ease of chewing, swallowing and speaking; and reduce common oropharyngeal problems, such as fungal infections in these patients.3
266
Conclusion The prosthodontic management of xerostomic patients is often more challenging. This paper provides the various treatment options for the management of xerostomia in complete denture patients. The combination of various treatments seems to be a better approach in the management of these patients. References 1. 2.
3.
4. 5.
6. 7. 8. 9. 10.
11. 12. 13.
14.
15. 16. 17.
Ship JA, Pillemer SR, Baum B. Xerostomia and the geriatric patient. J Am Geriatr Soc 2002;50(3):535-43. Mendoza AR, Tomlinson M. The Split denture: A new technique for artificial saliva reservoirs in complete denture. Aust Dent J 2003;48:190-94. Michael T, Leila J, Jonathan AS. Hyposalivation, xerostomia and the complete denture -A systematic review. J Am Dent Assoc2008;139(2):146-50. Guggenheimer J, Moore PA. Xerostomia: etiology, recognition and treatment. J Am Dent Assoc 2003;134(1):61-69. Ikebe K, Morii K, Matsuda K, Nokubi T. Discrepancy between satisfaction with mastication, food acceptability and masticatory performance in older adults. Int J Prosthodont 2007;20(2):161-67. Itthagarun A, Wei SH. Chewing gum and saliva in oral health. J Clin Dent 1997;8:159-62. Joel JN, Michael TB and Philip CF. Diagnosis and treatment of xerostomia (dry mouth). Odontology 2009;9:76-83. Rugg-Gunn AJ, Nunn JH. Nutrition, Diet and Oral Health. Oxford: Oxford Medical Publications, 2001;141-47. Silvestre-donat FJ, miralles-jordá L, martinez-V. Protocol for the clinical management of dry mouth. Med Oral 2004;9: 273-79. Shannon IL, Mccrary BR, Starcke EN. A saliva substitute for use in xerostomia patients undergoing radiation undergoing radiation therapy to the head and neck. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;44(5):656-11. Sinclair GF, Frost PM, Walter JD. New design for an artificial reservoir for the mandibular complete denture. J Prosthet Dent 1996 Mar;75(3):276-80. Joseph JM, David RC. Removable prosthodontic therapy and xerostomia. Treatment considerations. Dent today 2002;21( 6):80-87. Kam AY, McMillan AS, Pow EH, Leung KC, Luk HW. A preliminary report on patient acceptance of a novel intra-oral lubricating device for the management of radiotherapy related xerostomia. Clin Oral Invest 2005 Sep;9(3):148-53. Vergo TJ, Jr, Kadish SP. Dentures as an artificial saliva reservoir in the irradiated edentulous cancer patient with xerostomia. A pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1981 Mar;51(3):229-33. Hirvikangas M, Posti J, Makila E. Treatment of xerostomia through use of denture containing reservoirs of saliva substitute. Proc Finn Dent Soc 1989;85(1):47-50. Vissink A, Huisman MC, Gravenmade EJ. Construction of an artificial saliva reservoir in an existing maxillary denture. J Prosthet Dent1986;56(1):70-74. Villa A, Polimeni A, Strohmenger L, Cicciù D, Gherlone E, Abati S. Dental patients self-report of xerostomia and associated risk factors. J Am Dent Assoc 2011;142(7):81116.
