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Treating Xerostomia Patients DISEASES that can CONTRIBUTE to salivary flow dysfunction • Sjögren-Larsson syndrome – systemic autoimmune disease; immune cells attack and destroy the exocrine glands that produce tears and saliva. Pronounced SHOW-grins, this disease is common in those with fibromyalgia and chronic fatigue syndrome. • Lupus – collection of autoimmune diseases; a hyperactive immune system attacks normal, healthy tissues and can affect the joints, skin, kidneys, blood cells, heart, and lungs • Erythema multiforme – condition of the skin and oral mucous membrane ranging from a mild rash to life-threatening rash. Usually follows an infection or drug exposure. Peak incidence occurs in the second and third decades of life. • Von Recklinghausen’s disease (neurofibromatosis) – genetic disease in which patients develop multiple soft tumors (neurofibromas). Tumors occur under the skin sand throughout the nervous system. • Sialolithiasis – formation of calculus, or stones, in the salivary glands • Bell’s palsy – disorder of the nerve that controls movement of facial muscles. Damage to this nerve causes weakness or paralysis of these muscles. Cannot use muscles due to paralysis. • Stroke – rapid loss of brain function due to disturbance in the blood supply to the brain The submandibular salivary glands are located in the submandibular fossa of the mandible, or cleft, on both sides. Their ducts go into the ventral side of the oral cavity on either side of the mouth. It is very important for the surgeon who places implants not to drill their osteotomy into this area. Of course we’re using guided surgery with CT scans now, so those things are definitely less of an occurrence. All three sets of salivary glands are the main salivary glands that allow us to chew our food in our mouth. There are minor ones, too, some of which are called molar glands, but these are the three sets of two that are the most important. BB: We’ve talked about the causes of xerostomia, and we just reviewed the anatomy of the three sets of salivary glands. Can you tell us a little bit about the ways of diagnosing xerostomia? CT: That’s very important because you have to treat the patient who has xerostomia a little differently — a lot of the diagnoses come from the patients’ symptoms. One of the most important things, especially with women, is that they come in with lipstick on their teeth. Women who have lipstick on their teeth usually are experiencing a lack of salivary flow — there is no saliva there to rinse the lipstick off their teeth. That’s one of the first things I notice. The next thing I notice obviously is a dry mouth. Maybe thick and ropey saliva, almost a mucous-like saliva. Sore throats. Difficulty talking. Sometimes they’ll complain about a tongue that’s really sore all the time, and feeling thick — those kind of symptoms. And I ask specific questions in the initial consultation when the patient is sitting in my chair. Lots of them — especially, again, postmenopausal women — say they have a lot of these symptoms. It’s a tough nut to crack. BB: Are there other things you can detect from your patients, such as taste, or a malodor? CT: That’s correct. A lot of times there are specific causes of bad breath. Now, obviously, bad breath can be the result of periodontal disease or caries caused by salivary gland dysfunction. Because the saliva has certain bactericidal properties, bad breath, malodor, and a bad taste in their mouth can be symptoms of gland dysfunction. BB: And then you mentioned caries, lack of salivary flow can obviously affect that, right? CT: Tremendously, especially near the gingival tissues and the areas of the CEJ (cementoenamel junction) of the teeth. They become rampant caries, and it can be very difficult to treat. You have to go with certain preventive measures, such as using PreviDent ® (Colgate; New York, N.Y.) or some kind of fluoride rinse, drink water a lot, and so forth. BB: So if they have cervical lesions, does that become part of the differential diagnosis as to what’s causing that? CT: Correct. That is definitely one of the major pop-up symptoms. BB: As far as developing fungal and other infections, you mentioned the bactericidal properties of saliva. What are some other things that can show up? CT: It isn’t necessarily specifically from salivary gland dysfunction, but those people who have autoimmune problems or who are taking medications can have candida problems all throughout their body, especially the ladies. So what happens is they get candidiasis in their mouths, and a lot of the people I treat have to wear prostheses — either fixed or removable prostheses — and that can be a problem when you do get candida because it’s tough to keep treating it with Nystatin or Monistat ® (Insight Pharmaceuticals; 78 – www.inclusivemagazine.com –
A lot of times, having the prosthesis off the mucosa is something the patient can tolerate really well. And, of course, implants don’t have caries. Ways Sjögren’s Syndrome may affect the body Neurological problems, concentration/memory-loss (brain fog) Dry eyes, corneal ulcerations, and infections Dry nose, recurrent sinusitis, nose bleeds Difficulty swallowing, heartburn, reflux esophagitis Dry mouth, mouth sores, dental decay: difficulty with chewing, speech, taste, and dentures Recurrent bronchitis, pneumonia, interstitial lung disease Dry skin, vasculitis, Raynaud’s phenomenon Arthritis, muscle pain Stomach upset, gastroparesis, autoimmune pancreatitis Abnormal liver function tests, chronic active autoimmune hepatitis, primary biliary cirrhosis Peripheral neuropathy (numbness and tingling in the extremities) Vaginal dryness, painful intercourse Diagram of the many effects of Sjögren’s syndrome on the body, including symptoms that can contribute to xerostomia Courtesy of Sjögren’s Syndrome Foundation, www.sjogrens.org – Treating Xerostomia Patients: A Clinical Conversation with Dr. Christopher Travis – 79
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Inclusive Restorative Driven Implan
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Contents 19 Restoring Mandibular Si
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Publisher Jim Glidewell, CDT Editor
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Contributors ■ Bradley C. Bockhor
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Trends in Implant Dentistry Average
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my first implant with Jack A. Hahn,
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The House that Jack Built Inspired
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Hygienist’s Corner A Probing Ques
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Probe using only 0.15 Ncm of pressu
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Restoring Mandibular Single Teeth w
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Figure 4: Cross-sectional view of p
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Figure 13: Seated provisional resto
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Figures 26a, 26b: Acrylic abutment
Page 29 and 30: IMPLANT POSITION IN THE ESTHETIC ZO
Page 31 and 32: type of connection between implant,
Page 33 and 34: SMALL DIAMETER implants Planning fr
Page 35: Mandibular Spacing Maxillary Spacin
Page 38: used before the patient even presen
Page 42 and 43: BB: Sounds like it’s a truly inte
Page 44 and 45: Figure 6: Double-cord tissue retrac
Page 46: It’s a great time to be in dentis
Page 51 and 52: CLINICAL TIP Go online for in-depth
Page 53 and 54: 5a Figures 5a, 5b: A new bite regis
Page 55 and 56: Photo Essay: Immediate and Post-Pla
Page 57 and 58: 4a On the day of surgery, the risks
Page 59 and 60: With the implant securely hand-thre
Page 61: Case #2: Post-Placement Utilization
Page 65 and 66: 7a Once an appropriate osseointegra
Page 67 and 68: CLINICAL TIP When a Flapless Approa
Page 69 and 70: LAB SENSE Go online for in-depth co
Page 71 and 72: Digitally (CAD) Designed vs. Waxed
Page 73 and 74: mitigate the painful and disruptive
Page 77 and 78: Go online for in-depth content Trea
Page 79: BB: For the sake of our audience, c
Page 83 and 84: the time, and then I will prescribe
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Page 87 and 88: Figure 3: In2Guide surgical guide c
Page 89 and 90: Figure 13: Implants torqued to full
Page 91 and 92: Figure 22: Teflon plumber’s tape
Page 93 and 94: “Rules of 10” Guidelines for Su
Page 95 and 96: Some added concern is focused on th
Page 97 and 98: The all-on-four concept generally r
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