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ISSN No-2321-1482

DJAS 1(III), 144-151, 2013 Dental JOURNAL

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HOW TO MANAGE XEROSTOMIA IN PROSTHODONTICS???

Dr. Opinder Pal Singh1 Dr. Rubina2 Dr. Nikita3 Dr. Neeraj Mittal4 Dr. Rishi Saini5
1
PG Student Department of Prosthodontics and Crown & Bridge Bhojia Dental College, Distt. Solan, Himachal Pradesh (India)
2
Private Practitioner (India)
3
PG Student Department of Prosthodontics and Crown & Bridge Bhojia Dental College, Distt. Solan, Himachal Pradesh (India)
4
Senior Lecturer Department of Prosthodontics and Crown & Bridge Jan Nayak Chaudhari Devi Lal Dental College, Haryana (India)
5
PG Student Department of Prosthodontics, Genesis Dental College, Ferozepur, Punjab (India)
Corresponding Author:
1
Mobile: 919814348999 Email: [email protected]

ABSTRACT

Saliva is known as the mirror of the body. It is not only essential for retention of removable prosthesis but also
Received :
protects the oral mucosa from injury by its lubricating effect. Xerostomia or hyposalivation is a commonly
3rd July, 2013
encountered condition especially among the elderly that needs to be treated to improve quality of life in denture
Accepted: wearers. This article reviews the various etiologic factors and treatment modalities in patients with xerostomia.
18th Sept, 2013
Available online: KEY WORDS : Saliva, Xerostomia, Prosthodontics
28th Dec, 2013

INTRODUCTION base and the oral tissues. Xerostomia can make

wearing complete dentures difficult for the
Xerostomia is a common symptom among middle edentulous patient as it not only affects retention but
aged and older adults. This apparent age-related trend also makes the oral mucosa more prone to injury.
is thought to represent the influence of medical
conditions and their treatment rather than an age REVIEW OF LITERATURE
effect per se.1 Zora Blahova and Milan Neuman (1971)3 wrote
that viscosity of saliva helps prevent the dislodgment
Subjective dry mouth sensation is known as of denture, especially in the initial phase and so it
xerostomia, though when sialometry objectively becomes an important factor in retention.
demonstrates asaliva flow rate of under 0.1-0.2
ml/min (resting whole saliva) and under 0.7 ml/min Roy Y. Nakamoto (1979)4 described the use of a
(stimulated whole saliva), the term sialopenia or saliva substitute in postradiation xerostomia.
salivary hyposecretion is used. This condition is
equivalent to the secretion of less than 500 ml of R. E. Lindstrom, J. Pawelchak et al (1979)5 wrote
saliva a day.2 that retention fails at the moment the cohesive forces
in the saliva or other substances are overcome.
The prevalence of xerostomia is high among the
general population, and increases with age – affecting Thomas J. Vergo and Sidney P. Kadish (1981)6
approximately 30% of all individuals over age 65 designed a pilot study to test the feasibility of the
years.2 reservoir denture, a complete removable denture
prosthesis containing a reservoir chamber to hold and
Saliva plays an important role in the functioning of distribute artificial saliva in the irradiated edentulous
full dentures as prosthesis does not rest barely on patient with xerostomia.
mucous membranes but on an interposed salivary Joseph A. Toljanic and Terry G. Zucuskie (1984)7
film also. The retention of the complete upper described the use of a palatal reservoir in denture
denture and in a lesser degree of the lower, is also patients with xerostomia.
dependent on the salivary layer between the denture

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Mira Edgerton (1987)8 described the use of a saliva Salivary flow rates vary considerably during any one
as a significant factor in removable prosthodontic 24-hour period depending on the demand or the
treatment. He wrote that the artificial saliva currently current physiologic status of the patient15. The
available on the market is based on unstimulated flow rate is 0.3 mL/min, whereas the
carboxymethylcellulose, xylitol or mineral salts and flow rate during sleep is 0.1 mL/min; during eating or
have provided only short acting relief. Preliminary chewing, it increases to 4.0 to 5.0 mL/ min16. Any
results with artificial saliva based on animal mucin unstimulated flow rate below 0.1 mL/min is
have shown improved lubricating properties. considered hypofunction. Stimulated flow rate is, at
maximum, 7 mL/min. Stimulated saliva is reported to
M.M. Ferguson and M.J. Barker (1994)9 described contribute as much as 80% to 90% of the average
the use of saliva substitutes in the management of daily salivary production.17
salivary gland dysfunction.
CONDITIONS CAUSING XEROSTOMIA:
Gary F. Sinclair, Peter M. Frost et al (1996)10 gave Following conditions lead to xerostomia17
a new design for an artificial saliva reservoir for the 1. Chronic inflammatory disorders like Sjogren‟s
mandibular complete denture. syndrome, Rheumatoid arthritis, Systemic lupus
erythematosus and Systemic sclerosis.
Ana M. Diaz-Arnold and Cindy A. Marek (2002)11
2. Genetic disorders like Autoimmune thyroiditis,
wrote that in the partially or fully edentulous patient,
Cystic fibrosis, Sphingolipid storage disease,
susceptibility to mucosal ulcerations and fungal
Gaucher‟s disease, Thalassemia major and
infections may increase because of decreased salivary
Systemic amyloidosis.
flow. Patients should minimize denture use at times
3. Metabolic disorders like Primary biliary cirrhosis,
when decreased salivary flow is noted. Dentures must
Sarcoidosis and Diabetes mellitus.
be soaked in water overnight. The oral mucosa and
4. Viruses like HIV, Herpes viruses and Hepatitis C.
intaglio surface of aprosthesis can be sprayed
5. Other causes like end stage renal disease,
throughout the day with artificial saliva.
medications, dehydration, eating disorders
(anorexia / bulimia) and nutritional deficiencies.
Mark S. Chambers et al (2008)12 wrote that
irradiation of the major salivary glands induces DRUGS CAUSING XEROSTOMIA
changes in the volume, viscosity, pH, and organic Cytotoxic drugs, Drugs with anticholinergic effects
and inorganic constituents of whole saliva, including like atropine and antimuscarinics, Tricyclic
nonglandular components such as nonspecific debris antidepressants, Serotonin reuptake inhibitors,
(food residues), desquamated epithelial cells and Antihistamines, Antiemetics and Antipsychotics,
microorganisms. Deterioration of the salivary Drugs with sympathomimetic actions like
function leads to a loss in taste acuity, reduction of decongestants, bronchodilators, appetite
suppressants, amphetamines, other drugs like lithium,
whole saliva volume and increase in viscosity can
omeprazole, oxybutynin, disopyramide, didanosine,
impede prosthetic rehabilitation efforts and difficulty diuretics and protease inhibitors lead to diminished
with deglutition can impair the patient‟s appetite, salivary flow.17
leading to weight loss and immune suppression.
SIGNS AND SYMPTOMS OF XEROSTOMIA
AR Mendoza and MJ Tomlinson (2009)13 described Xerostomia, which can differ in degree of severity
a new technique for artificial saliva reservoirs in from one individual to another, may present itself
mandibular dentures. with one or more of the following symptoms –
difficulty in swallowing and speech, burning tongue,
NORMAL SALIVARY FLOW RATES stomatitis, halitosis, difficulty in wearing dentures,
Daily secretion of saliva normally ranges between
sleep interruptions due to thirst, increased dental
800 and 1500 milliliters. Under basal awake caries, salivary gland enlargement, angular cheilitis,
conditions, about 0.5 milliliter of saliva, almost oral candidiasis, papillary atrophy, opaque or viscous
entirely of the mucous type, is secreted each saliva, dessication or glossy appearance of oral
minute.14 mucosa, food debris or sloughed epithelium in the

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vestibule and audible clicking of oral soft tissues ARTIFICIAL SALIVA & SALIVARY
during speech.17 SUBSTITUTES
A number of patients with severe salivary gland
MANAGEMENT OF XEROSTOMIA dysfunction have inadequate functional tissue to
SYMPTOMATIC TREATMENT respond adequately to sialogogues and for this group
Sugar-free gum or candies may help to increase there is no alternative other than salivary substitute.
salivary output, but they may be inconvenient and Artificial saliva acts by humidifying and lubricating
affect patients‟ compliance. Chewing gums enhance the dehydrated oral mucosa. Likewise, it protects the
salivary flow rates, but these actions are transient and oral cavity against irritation and facilitates
the wearers of full dentures may be unable to use mechanical functions like speech and swallowing.
them. Frequent ingestion of sugar-free liquids may Saliva substitutes mainly consist of aqueous solutions
help. Water is the most important treatment for containing the same mineral salts as those found in
symptoms of dry mouth. The geriatric population is human saliva. As such, they mimic the natural
functions of these elements in the oral cavity. Salts
more susceptible to dehydration and should be
such as phosphates and calcium ions in particular
reminded to drink water on a regular basis. Sipping exert a key buffering effect to normalize the oral pH
water throughout the day keeps the oral mucosa and avoid chemical dissolution of the dental enamel,
hydrated and clears debris from the mouth. Sipping while restoring the demineralization/ remineralization
water during meals aids in chewing, swallowing and balance of the teeth.18
taste perception. Caffeine-containing beverages
should be avoided. Using a room humidifier Artificial saliva also usually contains enzymes with
antimicrobial action or mucins as lubricants. Saliva
increases environmental humidity and may improve
substitutes must be placed in the mouth by sucking,
patient‟s oral comfort.18 dripping, or spraying saliva from a container carried
in a pocket or purse.18
SYSTEMIC THERAPY
Symptomatic relief for xerostomia can sometimes be In an attempt to provide the necessary lubrication,
obtained by treatment with parasympathomimetics various solutions containing glycerol have been
such as pilocarpine hydrochloride or neostigmine compounded over the past century for lubricating and
bromide. Once the glandular activity has been moisturising the mucosa over a longer period than
stimulated in this way, the secretions may be does water alone. In some preparations, lemon juice
improved even after withdrawal of the drug. They or citric acid was also added to stimulate residual
stimulate water & electrolyte flow but require salivation but this is perhaps no longer appropriate as
residual functional salivary gland tissue. The optimal salivary substitutes are best reserved for those who
dosage of pilocarpine is 5 mg four times daily or 10 cannot respond to gustatory stimulation. In addition,
mg three times daily for at least eight to twelve repeated application of citric acid could further
weeks. Typical adverse effects are sweating, damage the already compromised dentition due to
headache, nausea, mild abdominal pain, low pH and its chelating action. Fermentation of
gastrointestinal upset, urinary frequency, chills, glycerol by oral bacteria is another potential
influenza-like symptoms, flushing, increased difficulty, with the local production of acids. As an
lacrimation and palpitations. Cevimeline reduces the extension of glycerol solutions, a pastille was
symptoms of xerostomia in patients with Sjogren‟s developed consisting of glycerol, gelatin, sucrose,
Syndrome. Therapy with cevimeline, 30 mg three lemon essence, amaranth and citric acid but such
times daily is well tolerated and provides substantive pastilles are not well coped with as they require a
relief of xerostomia symptoms. Carbacholine may be certain amount of moisture already to be present in
of benefit in the treatment of radiation induced order to dissolve. Over the ensuing decade, more
xerostomia. Pyridostigmine may be of benefit in the bland rinses were evaluated containing saline, sodium
treatment of drug-related xerostomia. Bromhexine bicarbonate or magnesium hydroxide. The rationale
(32-48 mg daily) may also increase salivary flow.18 of including an antacid was to raise plaque pH.9

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These appeared to assist in debridement of the mouth, Table 2- Composition of Mucin Based Saliva
similarly to water, and purportedly relieving Mucin 35.00 g
tenderness but again did not provide any significant Potassium chloride 1.20 g
lasting effect for severe cases of xerostomia. A dilute, Sodium chloride 0.85 g
aqueous solution of chlorhexidine has also been Di-potassium hydrogen orthophosphate 0.35 g
recommended for its bacteriostatic effect in an Magnesium chloride 0.05 g
attempt to parallel the antimicrobial functions of Calcium chloride 0.20 g
saliva, although this is a relatively non-specific Xylitol 20.00 g
Water to make total of 1 litre
approach. With the intention of producing a viscous
preparation, Matzker and Schreiber incorporated
sodium carboxymethyl cellulose in a phosphate- PROSTHODONTIC MANAGEMENT OF
XEROSTOMIA PATIENTS
buffered saline solution along with calcium and The Role of Saliva in Denture Retention
phosphate to limit enamel demineralisation. Delivery Saliva allows for the formation of a vacuum pressure
of saliva substitutes can be done in bottles and on the seating of dentures and contributes
canisters (sprays, gels and tubes), Denture reservoirs, significantly to denture retention and satisfaction
with the removable prosthesis. In the denture wearing
Pastilles and Infusion pumps.9 population, salivary wetting mechanics are necessary
to create adhesion, cohesion and surface tension that
Artificial saliva is divided into 2 groups: ultimately lead to increased retention of prostheses.
Carboxymethycellulose (CMC) based and Mucin Adhesion is the bond created by saliva between the
based. CMC is used to impart lubrication and oral mucosal epithelium and denture base. Cohesion
is the bonding between saliva components that leads
viscosity. Salts are added to mimic the electrolyte to greater retention of prostheses. Surface tension is
content of saliva. Calcium, Phosphate, Fluoride ions the denture‟s ability to resist separation from tissues
are added to provide remineralization potential. and is related closely to the fit of the prosthesis. An
Mucin is derived from porcine gastric tissues or intimate fit of denture bases to supporting tissues and
the presence of adequate border seals will provide
bovine submaxillary glands. Mucin based salivary
optimal denture function, provided that saliva is
substitutes are known to have the lowest contact adequate in amount, flow and consistency. Adhesion,
angle and the best wetting properties on the denture cohesion and surface tension are interrelated and they
base and the oral mucosa. Their rheological all depend on saliva. Saliva is also necessary to
properties are more comparable to that of natural prepare food for digestion and deglutition; its
insufficient output adversely affects nutrition in the
saliva (Table 1 & 2). 9 elderly edentulous population. Lack of saliva in the
denture mucosa interface can produce denture sores
Table 1-Formulation of Carboxymethylcellulose owing to lack of lubrication and prosthesis retention,
Saliva Substitute as well as to a reduction in the number of immune
Sodium carboxymethylcellulose 10.00 g factors that the salivary film provides. Lack of
Potassium chloride 0.62 g denture stability and retention can cause social
embarrassment if prostheses dislodge during common
Sodium chloride 0.87 g functions; they ultimately could impair a person‟s
Magnesium chloride 0.06 g ability or willingness to speak or eat, particularly in
Calcium chloride 0.17 g public. Therefore salivary hypofunction can have a
Di-potassium hydrogen orthophosphate 0.80 g devastating effect for the denture-wearing edentulous
Potassium di-hydrogen orthophosphate 0.30 g patient because of numerous compounding factors
Sodium fluoride 0.0044 g that affect chewing, swallowing, taste and speech.19
Sorbitol 29.95 g
Compound tartrazine solution 0.1 ml DRY MOUTH AND DENTURES
Methyl p-hydroxybenzoate 1.00 g Patients with salivary hypofunction are more
susceptible to mucosal candidiasis, which can
Spirit of lemon 5.0 ml
manifest as pseudomembranous covering or erythema
Water to make total of 1 litre
of the underlying tissues and a burning sensation of
the tongue or other intraoral soft tissues. In the

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patient with insufficient saliva, the lack of salivary Patients should be instructed to wet their prostheses
lubrication can produce traumatic ulcerations of the before applying adhesive and a combined use of
mucosa. The ulcerations manifest as small, painful artificial saliva and denture adhesive appears to be
lesions with elevated circumferential fibrous tissue. beneficial. Salivary substitutes, artificial saliva and
In patients who wear dentures, if the cause of the salivary stimulants can be beneficial for the denture-
ulceration is not treated, a frictional reactive wearing patient in terms prosthesis retention. During
hyperplasia can occur that develops into an epulis mealtime, greater intake of water is recommended.
fissuratum. Although there is insufficient scientific Although the use of adhesives in patients with
evidence regarding the use of denture adhesives in hyposalivation requires additional care, it often is
general, their use to enhance retention of well made necessary to stabilize a removable prosthesis.19
prosthesis is acceptable and, at times, necessary.
Moistened denture adhesives improve adhesion and SALIVARY RESERVOIRS IN DENTURES
cohesion and create a uniform fill of material, To provide easier application of artificial saliva, an
particularly on well-made prostheses, that improves intraoral saliva reservoir in the hollowed lingual
surface tension. Therefore, the use of adhesives in flange of a mandibular denture and palatal reservoir
patients who have hyposalivation can lead to are also the techniques of choice. These reservoirs
enhanced denture function and patient comfort. The help the patient control his xerostomia with the help
patient should be educated regarding the daily use of of salivary substitutes placed in them. Their results
adhesives and should be advised to visit the dentist were poor because adequate cleansing of the denture
annually to evaluate the adequacy of the prosthesis was difficult, which prevented flow of the saliva
and the health of the underlying denture-bearing substitute into the mouth.6,7,13
tissues. Idiopathic dysesthesia or stomatopyrosis
(commonly called “burning mouth syndrome”) is PROCEDURE FOR SPLIT DENTURE
diagnosed in patients with xerostomia who wear Clinically, primary and secondary impressions were
dentures by means of excluding fungal, traumatic, made in the normal manner. In the laboratory, a
mucosal, neoplastic, endocrine, serologic or duplicate of the secondary models was then made.
nutritional causes. It is characterized by a burning The duplicate models were then marked “Number 2
models”. The maxillomandibular relationship was
sensation in one or several oral structures in contact recorded with the mandible in retruded position and
with the dentures. These patients‟ oral mucosa have a an acceptable freeway space. The models were then
normal clinical appearance; the cause may be that articulated in the normal way and the teeth set up for
microfriction of the denture against the mucosa try in. Shorter teeth were used in the lower rim to
induces a dysesthesia.19 allow a deeper area for future placement of
reservoirs. The wax dentures were then tried in
TREATMENT OF DRY MOUTH PROBLEMS clinically. Using “Number 2 models” created after
IN DENTURE WEARERS the secondary impression, and the wax dentures, a
Initial therapy begins with a thorough assessment of second articulator is set up with identical
maxillomandibular relationships.13
the underlying cause. In elderly patients, assessment
must include a review of concurrent medical Construction of the clear acrylic mandibular base:
problems and medications. In the denture-wearing - The height of the clear acrylic base section first had
patient, the assessment must include the denture and to be determined. This was done by measuring the
the denture-bearing mucosal surface. If the dentist anterior height of the mandibular denture. Then the
can see denture sores, he or she should consider that a height of the lower anterior teeth was measured and
poor denture fit may be a causative factor in the 3mm added on to allow for sufficient acrylic under
patient‟s salivary hypofunction and must treat it. This the teeth for strength (Figure 1). The original wax
typically is the case for overextended mandibular dentures were then set aside and a new mandibular
wax base was constructed, on the original articulator,
lingual flanges. Excessive pressure in the lingual to this base height. Five studd-buttons are positioned
anterior regions potentially can cause mucosal in the wax. These are placed exactly in the centre of
soreness as well as hypofunction of the sublingual the wax base and waxed in such a way that only the
and submandibular glands and it requires adjustments studd were above the wax. The rim was then waxed
to the prosthesis.19 down to the model and flasked in the normal manner.
Because accuracy was critical, vacuum mixed, hard

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 Dental Journal of Advance Studies Vol. 1 Issue III-2013

stone was used. Once the wax was boiled out, stone duplicate in the corresponding position to the
separating medium was applied, the flask was packed clear acrylic base, a wax squash bite was made on the
with clear, denture acrylic. This was heat processed articulator, between the upper wax denture and the
as per manufacturer‟s instructions. After processing, clear acrylic base (Figure 5). The clear acrylic base
the clear acrylic base was deflasked. Care was taken was then removed and the stone duplicate placed in
in polishing to ensure that the square, occlusal edges its position. This was then plastered into place
were maintained (Figure. 2).13 (Figure 6). The teeth were arranged and waxed into
position in the normal manner (Figure 7). The
Construction of the upper mandibular section dentures were then flasked and processed in pink
Using the second articulator with the „Number 2 acrylic. After deflasking, the upper segment of the
models‟, the wax upper denture was placed on the mandibular denture was attached to the lower
upper model and the clear acrylic base placed on the segment for polishing (Figure 8). The two sections
lower model (Figure 3). To allow the upper section of should „click‟ into place at this point. Polishing was
the mandibular denture to be processed separately, it done with the segments together to ensure a flush,
was waxed up on a duplicate of the clear acrylic base. smooth finish and no damage to the edges. The result
This duplicate was formed by making an impression was a full lower denture with a clear acrylic base and
of its occlusal surface in a stock tray and pouring it a removable, pink acrylic upper section (Figure 9).13
up in die stone (Figure 4). In order to articulate this

Figure 1: Determination of height of Figure 2: Processed clear acrylic base Figure 3: Wax Upper denture against
acrylic base with studd buttons clear acrylic base

Figure 4: Duplicate of clear acrylic Figure

Figure5:4: Wax squashof bite
Duplicate clearmade in
acrylic Figure 6: Die-Stone duplicate placed in
base formed in die stone modelling wax position
base formed in die stone

,
Figure 7: Teeth arrangement and wax up Figure 8: Lower part (Clear acrylic) & Figure 9: Final lower denture
done, Upper part (Pink acrylic)

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 Dental Journal of Advance Studies Vol. 1 Issue III-2013

Denture issue and reservoir placement:- The CONCLUSION

denture, still with no reservoirs, was now issued to Mechanism of retention is a highly complex one,
the patient and worn for a time to allow the patient to under the control of numerous factors. Chief among
adjust and complete any minor adjustments. Once them are the forces related to the wetting of the
this was achieved, reservoirs were cut into the clear, denture and the surface tension, adhesive and
acrylic base of the denture. Because a clear acrylic cohesive characteristics of the saliva, without which
was used for the base section, the extent of the denture wearing becomes a painful process. Thus
reservoirs could be clearly visualized (Fig.10). The saliva plays a profound role in the maintenance of
reservoirs were made as large as possible while oral health in the denture wearing patient. Since the
maintaining sufficient thickness of the denture walls quality & quantity of saliva have an important role in
for strength. A minimum thickness of 2mm was the success of complete dentures, the patients with
maintained for the reservoir walls. Once the hyposalivation need to be treated to prevent adverse
reservoirs were placed, a 0.5mm diameter rose bur effects on the oral mucosa.
was used to drill a drainage hole from the inferior
aspect of the lingual flange of the denture into the REFERENCES
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Source of Support: Nil, Confilict of Interst: None Declared

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