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Assessing Salivary Gland Hypofunction—Part II

Building from an understanding of the diagnostic considerations for assessing salivary gland hypofunction,1 this column focuses on treatment considerations and implications for oral healthcare. The presence of saliva is critical to the maintenance of oral healthcare, and the lack of this substance has a tremendous negative impact on the patients’ oral care and quality of life. Patients with salivary gland hypofunction may have increase dental caries, periodontal disease, oral fungal infection, perioral bacterial infections (ie, parotitis), and greater risk of recurrent coughs and bronchial infections. Such patients, therefore, require an aggressive preventative treatment protocol.

There are presently several drugs on the market to increase salivary flow in patients with hypofunction. Pilocarpine is a cholinergic parasympathomimetic agent with predominately muscarinic actions that can increase secretion of exocrine glands. When the appropriate dose is provided, the nonspecific secretion may affect the sweat, salivary, lacrimal, gastric, pancreatic, and intestinal glands, as well as the mucous cells of the respiratory tract. While the oral form is labeled for use in head and neck radiation patients and patients with Sjogren’s disease, significant and potentially unpleasant adverse effects have been associated with this medication.

A sufficient dose of cevimeline, a cholinergic agonist that binds to muscarinic receptors, can increase the secretion of exocrine (ie, salivary and sweat) glands and can be used for Sjogren’s disease. There are also potentially unpleasant adverse events associated with this medication, to a significantly lesser degree than pilocarpine. As with any medication prescribed, the practitioner should review appropriate indications and contradictions and discuss this information with the patient.

Crystalline maltose also improves salivary output and decreases symptoms of dry eyes and mouth in patients with primary Sjogren’s syndrome. While the exact mechanism of action is unknown, the efficacy of this medication may be related to down regulation of glandular inflammatory immunologic activity. No significant side effects have been associated with this agent, and it is available without prescription.

Preventative protols (eg, frequent dental prophylaxis, use of supplemental fluoride rinses or gels, fluoride varnishes, meticulous oral home care) should be employed for patients with salivary hypofunction. Antimicrobial agents (eg, chlorhexidine gluconate rinses) reduce the number of oral flora associated with dental caries, periodontal disease, and oral candidiasis. Retrograde ingress of oral flora through salivary orifices and ducts is associated with parotitis—a significant and painful condition. The use of antimicrobial rinses twice a week may have a beneficial effect on reducing the oral flora associated with such conditions.

Treatment of oral candida infections may require use of oral rinses or systemic medications.2 Patients may not have adequate salivary function to allow traditional treatment and oral troches to dissolve effectively. In a dry environment, troches may actually cause mucosal abrasion and result in decreased patient compliance. For patients with removable oral prosthesis, frequent disinfection is recommended.2 

Studies have demonstrated that salivary output improves with the act of mastication. Patients should, therefore, chew sugarless gum daily to improve salivary flow. Similarly, impaired mastication is associated with a reduction in the mass of salivary tissue and a decrease in the synthesis and secretion of saliva.3 Maintaining masticatory function is, therefore, related to salivary output.

Unfortunately, an increased risk for dental disease is frequently manifested as tooth loss and edentulism in hypofunctioning patients. Decreased salivary output has a direct correlation with increased prosthetic functional difficulty in edentulous patients. Clinicians should consider recommending implant borne prosthesis and employ sialogogues and antimicrobial agents. The dental team plays a pivotal role in maintaining oral healthcare for all patients, especially patients with salivary hypofunction. While the results extend beyond the oral cavity, the benefits may improve functionality and quality of life.

 

*Director of Hospital Dentistry, Division of General Dentistry, East Carolina University School of Dental Medicine, Greenville, NC

 

References: 

  1. Muzyka BC. Assessing salivary gland hypofunction—Part One. Pract Proced Aesthet Dent 2001;13(9):688.
  2. Muzyka BC, Glick M. A review of oral fungal infections and appropriate therapy. J Am Dent Assoc 1995;126(1):63-72.
  3. Sreebny LM. Saliva in health and disease: An appraisal and update. Int Dent J 2000;50(3):140-161.
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