tends to be undertreated compared with xerophthalmia, partly because treatment modalities used for xerostomia are often ineffective [29].

6.7.5Management of Hyposalivation

This is discussed in Chap. 36.

6.7.6Chronic Complications of Hyposalivation

Chronic complications of hyposalivation are shown in Box 6.1:

Box 6.1: Chronic Complications of Hyposalivation

•Tooth demineralization and caries.

•Gingival changes

•Difficulty with chewing.

•Impairment of denture use.

•Swallowing difficulties.

•Oral malodour.

•Altered taste.

•Mucosal dryness and sensitivity.

•Oral infections (candidiasis and bacterial sialadenitis).

6.7.6.1Dental Caries

SS is often suspected because of a particular predisposition to dental caries [30, 31]. Box 6.2 illustrates the optimal approach to the prevention of dental caries. Dietary control of sucrose intake, the daily use of fluoride toothpastes, other fluoride applications, and frequent visits to the dentist are essential.

Calcium and phosphate are essential components of enamel and dentine. They form highly insoluble complexes, but in the presence of casein phosphopeptide – a group of peptides known as “CPP” – calcium and phosphate remain soluble and biologically available as amorphous calcium phosphate (ACP). A therapeutic CPPACP complex can be applied to teeth by means of chewing-gum, toothpaste, lozenges, mouth rinses, or sprays, providing bioavailable calcium and phosphate ions that aid remineralization of white spot lesions in an effect similar to self-applied fluorides. CPP-ACP also reduces the appearance of new caries in patients with xerostomia [32].

Another therapeutic approach to the management of sequelae of xerostomia is the use of a supersaturated calcium phosphate rinse in conjunction with 1.1% NaF for daily use [33].

Box 6.2: Strategies for Reducing Dental Caries in Patients with Sjögren’s Syndrome

•Frequent dental visits for early detection of caries

•Prevention of demineralization and encouragement of remineralization through the use of:

–Sodium fluoride: 1.1% neutral gel Lozenges 0.05% rinse

5% varnish Difluorosilane 1% varnish

–Calcium/phosphate:

Recaldent containing chewing gum Caphosol

6.7.6.2Periodontal Health

Gingival capillary alterations have been described in SS [34], but predilections to gingivitis and periodontitis are not documented as well as the risk of varies [35–37]. The true relationship between SS and periodontitis, if any, remains unclear.

6.7.6.3Oral Functional Impairments

Chewing may be impaired but patients with reduced or increased salivary flow do not show objective alterations in masticatory efficiency [38].

Denture use and function are impaired, but few studies describe the effects of hyposalivation on denture retention [39].

6.7.6.4Oral Infections

The risk of oral infections such as candidiasis and bacterial sialadenitis is increased in SS. Despite effective oral hygiene, more SS subjects than controls have detectable levels of oral yeasts [40]. The load of Candida in patients with SS is relevant to the level of salivary flow rates [41].

Frank candidiasis may be seen, particularly if there are other predisposing factors (Box 6.3). However, denture-related stomatitis with or without angular stomatitis (cheilitis) is more common. These are also complications of Candida infection.

Box 6.3: Factors Predisposing to Oral Candidiasis

•Disturbed local oral ecology or marked changes in the oral microbial flora by antibiotics, corticosteroids, xerostomia, dental appliances [42, 43]

•Heavy smoking

•Systemic conditions

–Immune defects

Malnutrition and dietary factors HIV/AIDS

Extreme old age Diabetes mellitus

Malignant and chronic diseases Blood dyscrasias

–Cancer therapy

Radiation to the head and neck Chemotherapy

6.7.6.5Denture-Induced Stomatitis

Denture-induced stomatitis (denture sore mouth; chronic atrophic candidiasis) consists of mild inflammation of the mucosa beneath a denture – usually a complete upper denture [43]. This is a disease mainly of the middle-aged or older people, more prevalent in women than men. Predisposing factors are xerostomia and the wearing of dentures throughout the night. Dentures can produce a number of ecological changes; they often lower the pH between the maxillary denture and oral mucosa, alter the oral flora, and allow plaque to collect between the mucosal surface of the denture and the palate. The accumulation of microbial plaque (bacteria or yeasts) on dentures and within the fitting surface between the denture and the underlying mucosa produces an inflammatory reaction. When candida is involved, the more common terms “Candida-associated denture stomatitis”, “denture-induced candidiasis”, or “chronic atrophic candidiasis” are used.

The characteristic presenting features of denture-induced stomatitis are chronic erythema and edema of the mucosa that contacts the fitting surface of the denture. Complete upper dentures are the type of dental appliance most often associated with this complication. The erythema is restricted to the denture-bearing area and is usually asymptomatic. Complications are uncommon, but include angular stomatitis.

The denture plaque and fitting surface is infested, usually with Candida albicans.

Therefore, to prevent recurrence of denture-induced stomatitis, dentures should be left out of the mouth at night and stored in an antiseptic. Denture cleansing and disinfection that includes removal of Candida is a necessary and important factor. Cleansers can be divided into groups according to their main components: alkaline peroxides, alkaline hypochlorites, acids, disinfectants, yeast lytic enzymes, and proteolytic enzymes. The latter are found to be the most effective against Candida. Denture soak solution containing benzoic acid is absorbed into the acrylic resin and eradicates Candida albicans from the denture surface as well as the internal surface

of the prosthesis. An oral rinse containing chlorhexidine gluconate results in complete elimination of C. albicans on the acrylic resin surface of the denture, and in reduction of palatal inflammation. A protease-containing denture soak (Alcalase protease) is also an effective way of removing denture plaque, especially when combined with brushing.

The mucosal infection is eradicated by brushing the palate and using miconazole gel, nystatin pastilles amphotericin or fluconazole, administered concurrently with an oral antiseptic such as chlorhexidine which has antifungal activity.

6.7.6.6Angular Stomatitis

Patients are predisposed to angular stomatitis (perleche, angular cheilitis) by the wearing of dentures. Other risk factors are iron deficiency, hypovitaminosis B, malabsorption states (e.g. Crohn’s disease), orofacial granulomatosis, Down’s syndrome, HIV infection, diabetes, and other disorders associated with immunodeficiency. Most patients with angular cheilitis also have denture-induced stomatitis. Infective agents can be isolated in up to 54% of lesions, usually

Candida albicans, but Staphylococcus aureus or streptococci may also be cultured from lesions.

Clinical features include soreness, erythema, and symmetrical fissuring at the angles of the mouth. In the treatment of angular cheilitis, it is important to apply an topical antifungal agent such as miconazole gel and to encourage smoking cessation. Lesions that respond poorly to these lesions may require topical fucidin or systemic fluconazole.

6.7.6.7Candidiasis

Candidiasis may cause soreness or burning and thus should be treated with antifungals until there is neither erythema nor symptoms (Box 6.4).

Box 6.4: Drug Treatment to Manage and Prevent HyposalivationInduced Candidiasis

•Clinicians should be aware that some antifungal agents contain sugar products. These contribute to the overgrowth of Candida. In contrast, nystatin vaginal tablets do not contain sugar. These can be administered orally two or three times daily to treat oral candidiasis.

•Sips of water should be given as necessary to dissolve the tablets

•Topical antifungal cream should be applied to the denture surface