in environmental humidity is important. Patients, especially in the winter time often experience a worsening of their symptoms. Use of room humidiÞers, particularly at night, may reduce discomfort [25].

14.3.2.2 Control of Plaque/Biofilm Formation

Dental caries is the clinical symptom of an infection with cariogenic bacteria. The most efÞcient way of treating caries is, therefore, to focus on removing the etiological factor, the bacteria in the bioÞlm, instead of merely treating symptoms by way of repairing cavities. Meticulous plaque control through excellent oral hygiene is important in prevention of dental caries. Patients should be instructed to brush their teeth at least twice per day using a soft bristled toothbrush and a low abrasive, highly ßuoridated toothpaste or gel. Daily ßossing is recommended. By simple measures, it is possible to measure levels of bacteria in the oral cavity, for instance, using stimulated saliva and the Dentocult R SM or Dentocult R LB (Orion Diagnostica Oy, P.O. Box 83, FI02101 Espoo, Finland) for Streptococcus mutans and Lactobacilli, respectively. Elevated levels of cariogenic bacteria are found in the majority of patients with SS [100, 101]. High (>1,000,000 colony-forming units (CFU)/mL saliva) levels of lactobacillus may indicate a diet high in carbohydrates. For dietary advice, see below.

Not only the teeth, but the dental ful or partial prostheses require minute cleaning as well. Oral and dental prostheses are preferentially cleaned using a conventional dishwashing liquid as toothpaste may roughen up the surface making the prostheses more ÒavailableÓ to bacterial deposits. To reduce the number of bacteria, rigorous plaque control is of the essence; thorough cleaning of teeth, tongue, and oral cavity morning and night with non-abrasive toothpaste and an electric toothbrush and interdental brush, ßoss, or toothpicks [102]. Alternatively, rinsing with a 0.2% chlorhexidine digluconat solution can be employed on a daily basis for up to 4 weeks [103]. In patients with sensitive oral mucosa, chlorhexidine can be diluted 1:1 with water to a concentration of 0.1%. In cases where hygiene

cannot be improved, 1% chlorhexidine gel can be used in an individually Þtted soft acrylic tray or used as toothpaste. An application schedule of 3 × 5 min for 2 consecutive days is recommended. Cleaning and ßuorides (see above) should be applied directly following meals.

14.3.2.3 Dietary Advice

Patients with salivary hypofunction have reduced oral clearance, causing increased retention of food and debris in the oral cavity [4]. Patients are therefore advised to reduce their food intake to a maximum of 5 meals/day, to drink a lot of water, and avoid soft and sticky food. Brushing with toothpaste after each meal or rinsing the mouth immediately after eating in order to remove food debris is advised. A recent study has shown that chewing sugar-free gum immediately after a meal may reduce the incidence of dental caries [75].

Liquid diets promote the formation of bioÞlm on teeth, and hot and spicy food can cause irritation or dry oral mucosa. Sugar, coffee, and alcohol also aggravate oral dryness. Patients should be encouraged to consume non-cariogenic foods and to maintain diets that enhance saliva secretion by proper chewing. Preferentially, patients should limit intake of foods and beverages that increase oral dryness, use sweeteners instead of sugar in coffee and tea, and avoid sweets and sugarsweetened soft drinks. During meals, patients should be encouraged to sip water and rinse the mouth thoroughly with water following each meal [4]. Patients with SS should be encouraged to carry water with them at all times. Frequent sips of water will help to relieve dryness, ease swallowing, hydrate tissues, and cleanse the mouth [25]. In cases of nocturnal oral dryness, patients can be advised to let water rinse the mouth before swallowing.

Milk is a good source of protein containing all essential amino acids [104]. With cheese, milk is also one of the major sources of calcium in Western diets, although the amount of calcium, phosphates, and magnesium depends on the type of cheese and processing [105]. Cultured dairy products such as yogurt and buttermilk have a relatively low pH of 3.5Ð4.5. Nonetheless, due to

the content of phosphate and calcium, the risk of erosive damage to teeth is low, and instead teeth are remineralized. In addition to calcium, phosphate, and proteins, milk contains lipids, all to which anti-cariogenic properties can be ascribed [104, 106, 107], and milk may be used for ÒsipsÓ between meals.

The proteins in milk can be divided into caseins (80%) and whey proteins (20%) [104]. Casein phosphate peptides inhibit the growth of cariogenic bacteria such as S. mutans. In addition, they can form calcium phosphate on the tooth surface and provide a reservoir of calcium and phosphate ions, which buffer pH in plaque and provide ions that can remineralize the tooth [104]. Milk and dairy products can also affect and reduce bacterial adhesion to the tooth surface, change the composition of the bioÞlm, and improve the buffer capacity of the pellicle [104].

Patients should also be aware of the increased risk of tooth wear associated with hyposalivation or/and low buffering capacity [26, 108Ð110], and patients with low salivary ßow should be aware not to consume acidic foods and beverages such as carbonated sodas in excess.

14.3.2.4 The Time Factor

Due to oral discomfort, tooth sensitivity, and mucositis, patients with SS may have problems with effective removal of dental plaque. With increasing awareness from the rheumatologist, dentist, and the patient, dry mouth patients can be diagnosed at an earlier time point and unnecessary destruction of dental hard and soft tissue be avoided.

Regular check ups every 3 months for followup at a dental clinic are recommended, with standardized control X-rays as often as every 6 months to monitor caries progression. Visits should contain dental plaque control and removal, dietary instruction, and advice, based on the patientÕs dietary history, as well as regular topical application of ßuorides, e.g., Duraphat R , Fluor Protector R , or 2% NaF, to reduce caries activity and to help preserve the dentition.

Frequent appointments are necessary for regular topical ßuoride application and control of

and motivation for oral hygiene. Because caries at the gingival interproximal margins can progress quickly, patients with SS should also have frequent, high-quality bitewing radiographs. If caries cannot be controlled, extensive Þxed prosthetic restorations are unwise and patients should be informed that former and present restorative work is susceptible to decay and may fail quickly [71].

14.3.3Candida Infections—Prevention and Treatment

Candida albicans is part of the oral, commensal ßora and will in stable health conditions colonize the oral cavity in small amounts. In situations where the immune system is suppressed or the anti-microbial effects of saliva are lacking as in SS, C. albicans may multiply and cause lesions in the soft tissue [68]. Patients with partial or full dentures with denture stomatitis often suffer from C. albicans infection, indicating suppression of the local immune system.

Infections with C. albicans may be asymptomatic, and lack of treatment is common. In patients with symptoms of oral candidiasis, an oral smear of the lesion is advisable. It is also possible to cultivate Candida from a chairside stimulated saliva sample by using for instance Dentocult R CA, which indicates excessive presence of C. albicans as brown colonies (Orion Diagnostica Oy, P.O. Box 83, FI-02101 Espoo, Finland).

Preferred treatment of oral candidal infections is topical application, as it allows the medication to be in direct contact with the tissues and the organism for a sufÞcient amount of time for control and elimination, reviewed in Soto-Rojas et al. [111].

Anti-fungal medications include nystatin, clotrimazole, and miconazole in the form of a gel, ointment, cream, suspension or vaginal tablets, to be used for weeks or months (Table 14.2). For mild cases of candidiasis, a suspension of nystatin (1,00,000 units) can be swished in the mouth following meals four times a day for 7 days, or a clotrimazole lozenge can be dissolved in the

mouth. The corners of the mouth can be treated effectively with a nystatin ointment [69].

Oral rinses are useful for patients with dry mouth who may have difÞculty in dissolving tablets. Unfortunately, some products intended for oral use are sweetened with sugar, thus predisposing dentate patients to dental caries. In more severe cases, ketoconazole or ßuconazole may be administered for 7Ð10 days [69].

Poor oral hygiene predisposes individuals to Candida infections, hence dentures or oral prostheses should be removed at nighttime, thoroughly cleaned as previously described, and periodically disinfected using either sodium hypochlorite or chlorhexidine. Patients should also be encouraged to drink more water and use mouth moisturizers and saliva replacements, see Section 14.3.2 and Table 14.2 for recommendations. Consumption of sugar-free yogurt containing active yeast cultures may help to control oral fungal populations [25].

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