|Ahead of print publication
Maxillary reservoir denture to overcome radiation-induced xerostomia – Light at the end of the tunnel
Sudhanshu Srivastava1, Preety Negi2, Devendra Chopra1, Sumit Misra1
1 Department of Prosthodontics, Saraswati Dental College, Lucknow, Uttar Pradesh, India
2 Department of Radiotherapy, Christian Medical College, Ludhiana, Punjab, India
|Date of Submission||13-Dec-2018|
|Date of Decision||12-Feb-2019|
|Date of Acceptance||21-May-2019|
|Date of Web Publication||31-Jan-2020|
Department of Prosthodontics, Saraswati Dental College, 14/98, Indira Nagar, Lucknow - 226 016, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Xerostomia is a subjective symptom of dry mouth. It can occur as a part of the systemic disease, drug-induced side effect, or following therapeutic radiation therapy to the head-and-neck region. The primary complication faced by these xerostomic patients is the difficulty in retention of removable dentures. It is important to recognize that the prosthodontic management of these patients requires special attention and care. In an attempt to overcome the presence of xerostomia, several techniques of introducing reservoirs into the dentures containing salivary substitutes have been proposed. This case report presents a simplified approach for the construction of a reservoir in the maxillary denture, specifically in patients where other treatment modalities have failed. This technique provided excellent lubrication to oral tissues, hygienic for the patient, and utilized routine denture base material.
Keywords: Lubrication, radiotherapy, reservoir denture, xerostomia
|How to cite this URL:|
Srivastava S, Negi P, Chopra D, Misra S. Maxillary reservoir denture to overcome radiation-induced xerostomia – Light at the end of the tunnel. J Can Res Ther [Epub ahead of print] [cited 2020 May 25]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=277464
| > Introduction|| |
Xerostomia is a common complaint compromising oral functions and the quality of life. Etiology of xerostomia is multifactorial such as Sjogren's syndrome, drug-induced side effects, salivary gland diseases, head-and-neck radiation side effects, and medical illness such as diabetes. The severity of the problem increases in an edentulous patient suffering from xerostomia because of the extreme discomfort in wearing the dentures. Presence of sufficient amounts of saliva within denture and tissue interface is essential. In the absence of adequate saliva, a denture will not attach to the tissues as a result of the loss of surface tension, thereby diminishing the retention of the dentures.,, Depending on the underlying etiology leading to xerostomia, various treatment options are available. Efforts to reduce the severity of radiation-induced xerostomia include stimulants of salivary gland function (e.g., parasympathetic drugs as pilocarpine and bethanechol), xerostomia prevention strategies (e.g., amifostine), use of salivary substitutes for symptomatic relief, and modern radiation therapy techniques (e.g., intensity modulated radiotherapy). An effective solution in edentulous patients with xerostomia is to achieve constant salivary substitute concentration into the patient's mouth without affecting the patient's daily routine. A perpetual flow of artificial saliva can be accomplished with the help of a reservoir embedded in the maxillary or mandibular denture. It has been proposed that incorporation of these reservoirs containing salivary substitutes into dentures can be offered to these patients, after the failure of all available treatment options. These salivary substitutes enhance lubrication and act as a wetting agent for the dry mucosa. They also provide symptomatic relief and thus promote the retention of an artificial prosthesis. The continuous delivery of these substitutes can occur over a longer period using saliva reservoir in edentulous xerostomic patients. This case report describes a simple and easy method for the fabrication of a reservoir in the maxillary denture to overcome the problem of xerostomia postradiation therapy.
| > Case Report|| |
A 70-year-old male patient presented to the Department of Prosthodontics, Saraswati Dental College, Lucknow, with chief complaints of dryness of mouth and discomfort while speaking and eating. The patient had a history of smoking 20 cigarettes/day and daily alcohol abuse for the last 20 years. His past medical history included Stage III squamous cell carcinoma left tonsillar pillar, for which he had had radiation therapy 19 months previously. He also had a history of hypertension and noninsulin-dependent diabetes mellitus and was on treatment for the same. Extraoral examination revealed cracks at the corner of the mouth. Intraoral inspection disclosed edentulous maxillary and mandibular ridges, areas of inflammation, dryness of tongue, and minimal saliva in the oral cavity [Figure 1]a and [Figure 1]b. As initial treatment, the patient's family doctor was contacted, and his hypertensive medications were altered. Multivitamin supplementations and use of salivary substitutes (methylcellulose) were advised. General measures included frequent sips of water to overcome the dryness and associated discomfort. A written informed consent was obtained from the patient.
|Figure 1: (a) Edentulous maxillary ridge, (b) Edentulous mandibular ridge|
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Fabrication of upper complete denture with salivary reservoir
- The primary impression was made in irreversible hydrocolloid. Putty rubber base impression material was utilized for primary impressions. Custom trays were fabricated, border molding was done, and secondary impressions were made in light body elastomeric impression material (Aquasil Ultra LV Dentsply Caulk)
- Occlusal rims were fabricated and jaw relation was obtained. Teeth were arranged on occlusal rims and try-in was done
- Two sheets of modeling wax of 2-mm thickness were adapted over the palatal surface of the maxillary denture base [Figure 2]. The reservoir was created by removing the center of the palatal wax. In the center of the palate, the putty was adapted to occupy the space needed for the reservoir [Figure 3] and [Figure 4]. Extra 2-mm bulk of wax was added over this putty in a proper manner to exactly fit the reservoir
- The trial dentures were finished and retried in the patient's mouth to check for retention, stability, phonetics, esthetics, and comfort. The patient consent was obtained to go ahead with the procedure
- The lid was cured separately, and the denture was cured in another flask simultaneously. Heat cure acrylic resin (Trevalon, Dentsply) was used for the processing of this assembly [Figure 5]
- After acrylization, finishing was done. The processed lid was permanently attached to the reservoir area with the help of self-cure resin [Figure 6]. The final assembly was polished. One inlet and three outlet holes of a size similar to 19 and 26 gauge needles, respectively, were made on the palatal aspect of the denture behind the central incisor area
- Artificial saliva substitute (wet mouth, ICPA Health Products Ltd., MUMBAI, INDIA) was then used for filling the reservoir space
- Various postinsertion instructions provided to the patient are:
- Guidelines were given to the patient with respect to oral care and denture maintenance
- Instructions were given to the patient regarding the cleaning of the reservoir space. The patient was schooled to clean the reservoir daily with a small brush and a fine orthodontic wire
- The patient was advised to flush out the reservoir with 1% sodium hypochlorite solution once a week
- The patient was told to fill the reservoirs 3–4 times a day with artificial saliva
- It was advised to drink at least eight glasses of water, lemon juice, or milk
- Postinsertion checkup was scheduled after 24 h, 1 week, monthly, and every 6 monthly thereafter.
The patient was evaluated after 6 months and was found to contend with the prosthesis. The symptoms of dry mouth were relieved. The patient also informed about the improvement in dietary intake and does not show any difficulty in speech.
| > Discussion|| |
A healthy person produces saliva in the range of 1–1.5 l/day. The unstimulated flow of saliva is mainly from submandibular gland constituting about 65%—20% from the parotid gland, 7%–8% from the sublingual gland, and <10% from the minor salivary glands, while stimulated flow of saliva is primarily from the parotid gland being responsible for more than 50% of total salivary secretions., Salivary flow value of <0.1 ml/min is considered as xerostomia. Xerostomia is documented as important acute and late radiation therapy sequelae affecting the quality of life of these patients. The exact mechanism responsible for radiation-induced xerostomia is unknown. It is thought that it occurs as a result of damage to the blood supply or signal transduction system damage or destruction of the gland itself because most of the salivary glands are included in the radiation fields for head-and-neck malignancy., Several causes have been held responsible for xerostomia such as anxiety, medications, reduced mastication, autoimmune diseases, or radiation treatment as in our case. Depending on the cause of dry mouth, numerous treatment modalities are available. However, these currently available treatment options for xerostomia are not very successful in bringing substantial comfort for the patient. The conjunction of various techniques is usually required for the success of the prosthesis. A prosthesis containing a reservoir space with the slow and continuous release of artificial saliva proves to an elective and promising treatment modality for the clinician.
The most important factor before considering the maxillary denture for the fabrication of a reservoir is the amount of interarch space. In cases of the shallow palatal vault, the utilization of palatal reservoir is contraindicated. The major problem associated with a palatal reservoir is increased palatal thickness which leads to a constricted oral space. This further leads to difficulty in swallowing and speech alteration. Thus, a thorough evaluation of phonetics should be done. Phonetics can be evaluated by observing the pronunciation of palatolingual consonants. It was observed that the tongue come in contact with the palate while producing palatolingual consonants such as s, t, d, n, and l. Hence, these were repeated and assessed for proper pronunciation.
Numerous techniques for incorporating a reservoir space in complete and partial dentures have been described in the literature. Shah et al. used a 2-mm thick ethylene vinyl acetate, but it required special equipment for its fabrication. Vissink et al. used rubber dam material which allows slow release of saliva, but its integration onto the prosthesis is technique sensitive and durability is questionable. Some clinical reports depicted the use of magnets. Their disadvantage was a loss of magnetic bonding, under a shearing load. It also requires exhaustive laboratory steps. Some authors' have also described the use of double tooth Lego blocks. The major disadvantages include lack of parallelism, difficulty in separating, and rejoining the two segments., Burhanpurwala et al. advocated the use of stainless steel press on buttons. They had the drawback of questionable fit, seepage of saliva, frequent loosening, and replacement. Furthermore, their resistance to corrosion is not known. Modgi advocated the use of the precision attachment. However, the major disadvantages include the cost and difficulties in achieving parallelism between attachments.
The primary advantage of a salivary reservoir in a maxillary denture is the large size of the reservoir which, in turn, enhances the salivary flow to the whole mouth. Further food on the floor of the mouth does not block the draining holes. Our case report depicts an easy and simple method of incorporating reservoir in a maxillary denture to overcome the problem of xerostomia in postradiation therapy patients. The design is very simple and does not involve any laborious laboratory steps or technique sensitive. Another benefit of this technique is a fabrication of maxillary reservoir denture, which required routine denture material. Since the method does not involve incorporation of any specialized equipment, the chairside time is also reduced. The perpetual flow of saliva from the reservoir adds to the comfort of the patient such as good lubrication of food for easy swallowing, maintenance of oral pH, and increased retention of the denture. The access to this type of reservoir is easy, hygienic, and provides good lubrication of oral tissues.
| > Conclusions|| |
The interest of this case lies in the specialized technique of fabricating maxillary saliva reservoir denture for the management of xerostomia in a cured patient of carcinoma oropharynx. This technique is simple; no special denture material is required and keeps the oral tissues moist. However, there is a need to develop reservoir chambers in an attempt to achieve the even more controlled release of artificial saliva, making the treatment more acceptable to patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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