Guide : Prof. Dr. Sarita Joshi

Presented By

Dr. Anjana Maharjan

2nd Year Resident, NAMS

Management of XerostomicPatients in Prosthodontics

Xerostomia

Condition associated with both a decrease in the amount of saliva produced and an alteration

in its chemical composition, therefore causing dry mouth

“Xero” Dry “Stomia”

Mouth

Medications with anticholinergic activity

Psychiatric comorbiditiessuch as mood and anxiety disorders

Medical comorbiditiessuch as HIV/AIDS, diabetes, renal failure and Sjögren’s syndrome

Radiation for head

and neck

malignancies

Causes

Medications: are the most common pharmacologic causes of include many antipsychotics, antispasmodics, antidepressants (especially the bronchodilators. common culprits, including alphaterazosinand betaMedicationresult from direct interference with or damage to salivary tissue (as with some cancer chemotherapies). benzodiazepines cause dry mouth, although the mechanisms are not known

Signs/Symptoms

Edentulous patients suffering from may complain of not only,drybut also difficulty in normal functions like eating, speaking, swallowing etc

Dry mouth

Cracking at corners of mouth

Burning sensation on tongue associated with fissuring of tongue

Alteration of taste

Problems encountered in denture

patients

Retention in complete denture

Increases frictional forces between

dentures and oral mucosa

Prone to denture stomatitis

Recommendation:

Management

Symptomatic treatment

Address underlying

causes

Stimulate residual

gland function

Saliva substitutes

Encourage oral

hydration

Optimize oral hygiene

Symptomatic treatment

Encouraged to sip water

Let ice melt in the mouth

Restrict caffeine intake

Coat lips with lubricant

Cautioned to avoid products

Address underlying causes

Physician consultation

Alter drug dosages

Substitute medication causing xerostomia

Control of systemic disorder

. If this is not feasible, titrate to lowest effective dose or modify dosing schedule. Replacing immediaterelease formulations of some drugs may help (e.g. with overactive bladder).

Control of systemic disorders (syndrome )

Stimulate residual gland function

Sugarless gums (xylitol / sorbitol) and candies

Cholinergic agonists :

Pilocarpine

Cevimeline

Sugarless gums and candies

Cholinergic agonists

Pilocarpine HCl

Dose : 5mg tid up to 90 days

Cevimeline HCl

Dose- 30mg tid up to 6 weeks

Contraindicationspatients with glaucoma, asthma, gastric ulcers

Pilocarpine

meals

Adverse effectchills, frequent urination , dizziness, head ache, facial lacrimationAdministered with caution in cardiovascular patient)

nervousthe

Efficacy of Secretion of Saliva: A Pilot StudyBrimhall

Spec Care Dentist.

Johnson J T, Ferretti G A, Nethery W J, et al. Oral pilocarpine for post-irradiation xerostomia in patients with head and neck cancer. New Eng J Med 1993; 329: 390-395

In the study done, 44% of patients reported improved salivation while on a dose of 5.0 mg Pilocarpine tid day

They concluded that many symptoms associated with postirradiation discomfort and speaking difficulty

Saliva substitutes

Glycerin and lemon

Carboxymethyl cellulose

Mucin

Newer products with enzyme systems such

as lactoperoxidase, lysozyme, and glucose

oxidase

They include as calcium, alcohols (e.g. cariogenicpotential.Theylubrication of the mucosa and help to clean teeth from bacteria and debris. Saliva substitutes areavailable as lozenges, rinses, sprays, swab sticks and as reservoirs Treatment with saliva substitute), based sugarchewing gum) and based saliva substitute) suggested

available and may be particularly useful at

Commercial Salivary Substitute

Xerostom

Basic ingredient - xylitol

Available as toothpaste, mouthwash, pastilles, oral spray and gum

Dry mouth GC

Basic ingredients:

Polyglycerol

Sodium citrate

The lubricating products should have a neutral pH range to keep oral irritation at a minimum and to control the high dental erosion risk in xerostomiaAmerica) was developed to stabilize oral pH in the neutral range.

Wet Mouth

Basic Ingredients:

Glycrine

Cellulose Gum

Take half/full quantity in cap and swish in

Each 5 ml contains Sodium cellulose 0.5%, flavoured

BioteneGums, Mouthwash and Toothpaste

OralbalanceMoisturizing gel

Patients are to swish thoroughly for 30 seconds

Epstein J B, Emerton S, Stevenson-Moore P. A double-blind crossover trial of Oral Balance gel and Biotene toothpaste versus placebo in patients with xerostomia following radiation therapy. Oral Oncol 1999; 35: 132-137

Compared use of Oralbalance gel and Biotene toothpaste against control of carboxymethylcellulose gel and commercial toothpaste

Patients using Oralbalance and Biotenereported these two products to be more effective than the controls

Prosthodontic Management

Fixed Prosthodontics

In dry environment, fixed non tissue bearing prosthesis are preferred where indicated

FPDs should have full coverage retainers and easily cleaned pontics and connectors

Margins of retainers should be supragingival

Health of residual teeth and periodontal tissues

Use of gingivally approching clasp avoided

Tooth supported denture with minimal tissue coverage

Metal denture bases are preferred

Removable Partial denture

Complete denture

Procedures -aim at optimizing retention and stability

Use dentures with metal bases

Use of soft liners to improve comfort

Use of denture adhesives to augment retention

Frequent recall – As more prone to candidalinfections

Saliva Reservoir-Technique

Upadhyay R, Kumar L, and Rao J, Fabrication of a functional palatal saliva reservoir by using a resilient liner during processing of a complete denture, JPD 2012;108:332-335

Encourage oral hydration

Humidifiers, especially during sleep

Optimize oral hygiene

Anti microbial mworal rinse, USP 0.12%, twice daily, may be effective in preventing dental caries and oral infections.

Biotène Dry Mouth Toothpaste contains salivary enzymes

Antimicrobial mouthwashes (alcohol-free)

Conclusion

Clinicians should be aware of the signs and symptoms, diagnostic procedures, etiologies, sequelae and appropriate therapeutic regimens

Effective evaluation and appropriate treatment will promote acceptable levels of comfort and function

Acknowledgement

Prof. Dr. Sarita Joshi

Coordinator, Prosthodontics

NAMS, Bir Hospital

Asst . Prof. Dr. Pramod Raj Joshi

Asst. Prof. Dr. Siddartha Dixit

Asst. Prof .Dr . Dipak Thapa

Residents of NAMS