Quality Resource Guide l Managing Dental Patients with Xerostomia and Hyposalivation 1st Edition 7 www.metdental.com Prevention & Treatment Ongoing dental care for patients with xerostomia must be provided with an emphasis on preventing dental caries, irrespective of the cause of xerostomia. The practitioner can provide guidance and monitor the patient, but patients must comply with and adhere to a meticulous oral hygiene regimen. Hygiene can be augmented with a power toothbrush and other oral physiotherapy aids. It is essential that patients frequently apply fluoride- containing dentifrices augmented with OTC or higher concentrations of prescription fluoride mouth rinses, chewable tablets, or gel applications with custom tray carriers for the prevention of the initial demineralization process (Figure 2) ( Table 4). Fluoride applications also enhance the remineralization of exposed root surfaces. Carious lesions can be restored with glass ionomer materials that provide ongoing fluoride release to the teeth. Recall visits at shorter intervals should be encouraged to monitor compliance with home care, promptly identify areas of demineralization, and restore early carious lesions. Office visits should include prophylaxis and the application of fluoride varnish. Dietary counseling should reinforce avoiding foods and beverages that contain fermentable carbohydrates and “hidden sugars.” The detriment of frequent sugar intake should be explained, and between-meal snacks discouraged. The patients’ physicians should be consulted to determine if their medication(s) can be substituted with alternate classes of drugs with less xerogenic side effects or if the dose can be reduced. Patients also should be educated about beneficial foods, weight loss, and exercise that could replace the need for medications. Alternatively, taking medication(s) in divided doses and not taking them before bedtime may provide additional benefit since saliva production is diurnal, with less secreted at night. Protocols for dry mouth generally include informing the patient to drink 6 to 8 glasses (8 ounces) of water daily and frequently sip dissolved ice chips, use emollients (coconut oil), and a humidifier in the bedroom. Frozen water can provide additional benefits. Small ice cubes containing a drop of lemon flavoring cool and moisten the mouth and stimulate salivary flow. Patients should be advised to avoid caffeine, tobacco, and alcohol, which are dehydrating and avoid certain dentifrices that contain sodium lauryl sulfate, which removes the protective mucin layer of the oral mucosa. Alcohol- free mouthwash products are advised. Patients are encouraged to use citrus-flavored sugarless gum/mints/candies. One sugar-free chewing gum (Migthteaflow gum and lozenges) stimulates salivary flow. However, this can only be effective if the patient has residual and functional salivary gland tissue with some natural salivary flow. Many OTC products are available as oral solutions, aerosols, sprays, gels, lozenges or troches to alleviate the discomfort associated with xerostomia (Table 5). They are formulated to function as saliva substitutes and replicate some of the constituents in natural saliva. These moistening agents may have a limited duration of action and require frequent re-administration; thus, the cost can be a consideration. The relative effectiveness of these products is patient and use-dependent and generally is best when combined with additional aspects of a dry mouth protocol. Two pharmacologic agents, pilocarpine and cevimeline ( Table 5), can stimulate salivary secretions provided the patient has residual and functional glandular tissue. Since these drugs require systemic administration to stimulate the cholinergic receptors of the salivary glands, they can cause side effects such as flushing, sweating, rhinitis, abdominal cramping, nausea, vomiting, and increased frequency of urination. It is advisable to consult with the patient’s physician before prescribing these drugs because of potentially medically significant systemic effects, including dizziness and blurred vision. Furthermore, they are contraindicated in patients with narrow-angle glaucoma, obstructive urinary or gall bladder disease, or a history of cardiovascular disease, particularly cardiac arrhythmias. Saliva electrostimulation devices are available OTC for extraoral or intraoral use. One intraoral device designed to stimulate the lingual nerve effectively increased salivary flow and reduced xerostomic symptoms among patients with Sjögren syndrome and other causes of xerostomia. A similar device, by prescription, can be embedded in a prosthesis, but both types can only be effective if the patient has residual salivary gland function. Complications such as dental caries and candidiasis are best managed by prevention. If dental caries develop, patients are optimally served if restorations are completed early in the course of the infection and accompanied by a thorough explanation of the importance of diet, saliva, and fluoride. Candidiasis is managed with antifungal agents listed in Table 5. These should be used daily for at least two weeks for the infection to resolve. If tolerated, alcohol-free chlorhexidine gluconate-containing mouthwash (Peridex®) can prevent recurrent infections in more susceptible patients. Keeping the mouth moist and using any of the agents listed in Table 5 may also reduce the risk of reinfection. The future holds much promise for patients who have hyposalivation. A clinical trial using viral vector delivery of an aquaporin gene is underway for patients with radiation-induced dry mouth. Aquaporin is a transmembrane channel protein that helps water diffuse across cell membranes. Conclusions This Guide provides the practitioner with information to help identify the causes, diagnosis, and management of xerostomia and hyposalivation and their complications. It is evident that managing patients with xerostomia and hyposalivation is challenging, and therapies continue to be developed. Irrespective of its cause, xerostomia or hyposalivation most often becomes a chronic condition that may be irreversible. Treatment should be focused primarily on the causes so that complications can be prevented.