Xerostomia, or dry mouth, is caused by decreased saliva production and affects many older adults. Saliva is important for maintaining oral health as it lubricates and cleanses the mouth, prevents infection, and aides in swallowing and digestion. In the elderly, reduced saliva flow can be caused by various medical conditions and medications which leads to increased risk of oral diseases. Proper diagnosis and management of the underlying causes of xerostomia in older patients is important for improving symptoms and quality of life.

1. Recurrent Aphthous Ulcer
• Etiology:
• Local altered immune response.
• Systemic etiologies include nutritional
deficiencies (iron, B6, B12), diabetes
mellitus, inflammatory bowel disease,
immunosuppression.
• Biopsy will rule out other
vesiculoulcerative disease.

2. Recurrent Aphthous Ulcer
• Appearance:
• Minor aphthous ulcer: <0.6 cm shallow
ulceration with gray pseudomembrane and
erythematous halo on non-keratinized
mucosa.
• Major aphthous ulcer: >0.5 cm ulcer, more
painful, lasting several weeks to months;
will scar.

3. Recurrent Aphthous Ulcer
• Differential Diagnosis:
• Herpes simplex virus.
• Chemical/traumatic ulcer
• Vesiculoulcerative diseases
• Squamous cell carcinoma
• Treatment:
• Topical analgesics
• Topical steroids

5. Inflammatory Conditions
(Denture Related of the Oral
Mucosa)
• Inflammatory papillary hyperplasia
• Epulis fissurata (inflammatory
fibrous dysplasia)
• Candidiasis

6. Inflammatory Papillary
Hyperplasia
• Etiology:
• Poorly fitting denture
• Occurs in more than 50%
of Denture Wearers
• Appearance:
• Multiple small polypoid or
papillary lesions.
• Typically on hard palate,
that produces a
cobblestone appearance.

7. Inflammatory Papillary
Hyperplasia
• Etiology:
• Poorly fitting denture
• Occurs in more than 50%
of Denture Wearers
• Appearance:
• Multiple small polypoid or
papillary lesions.
• Typically on hard palate,
that produces a
cobblestone appearance.

8. Inflammatory Papillary
Hyperplasia (Papillomatosis)
• Treatment:
• Discontinue using denture
• Surgical removal of hyperplastic tissue.
• Occasionally tissue conditioner may
reduce the problem, while reconstruction
of new denture may be necessary.

9. Epulis Fissurata (Inflammatory Fibrous
Dysplasia, Denture Granuloma)
• Etiology:
– Over-extended denture flanges.
– Resorption of alveolar bone that makes the
denture borders over-extended.
• Appearance:
– Hyperplastic granulation tissue surrounds the
denture flange.
– Pain, bleeding, and ulceration can develop.

11. Epulis Fissurata (Inflammatory Fibrous
Dysplasia, Denture Granuloma)
• Differential Diagnosis:
• Verrucous carcinoma
• Squamous cell carcinoma
• Traumatic fibroma
• Treatment:
• Small lesions may resolve if flanges of
denture are reduced.
• Surgical excision is necessary prior to
rebasing/relining of denture.

12. Oral Candidiasis

13. Candidiasis
• Four fungal organisms: Candida albicans,
Candida stellatoidea, Candida tropicalis, and
Candida pseudotropicalis.
• Candida albicans is most common.
• Morphologically, presents in 3 forms: yeast
cell, hypha and mycelium (last form is
pathogenic phase).
• Carriers of oral candida do not show the
mycelial phase.

14. Etiology
Mixed infection of Candida albicans,
staphylococci and streptococci.

15. Classification of Oral
Candidiasis
• Acute pseudomembranous candidiasis
(moniliasis, thrush).
• Acute atrophic candidiasis (antibiotic sore
tongue).
• Chronic atrophic candidiasis (denture stomatitis).
• Chronic hyperplastic candidiasis (candidal
leukoplakia, median rhomboid glossitis).
• Angular cheilitis
• Chronic mucocutaneous candidiasis.

16. PAS Stained Candida Albicans
Hyphae Embedded in The Oral Mucosa

17. Acute Pseudomembranous
Candidiasis (Thrush)
• Etiology:
• Oral candidiasis
• Appearance:
• White slightly elevated plaques that can be
wiped away leaving an erythmatous base.
• Direct smear can be fixed and stained
using PAS reagent to reveal the candida
hyphea microscopically.

19. Acute Atrophic Candidiasis
(Antibiotic Sore Tongue)
• Etiology:
• Oral candidiasis secondary to antibiotics
or steroids.
• Appearance:
• Similar to thrush without overlying
pseudomembrane: erythematous and
painful mucosa.
• Differential Diagnosis:
• Erosive lichen planus.
• Chemical erosion.

21. Chronic Atrophic Candidiasis
(Denture Sore Mouth)
• Etiology:
• Most common form of oral candidiasis;
candidal infection of denture as well.
• Treatment should be directed towards
mucosa and denture.

23. Chronic Atrophic Candidiasis
(Denture Sore Mouth)
• Appearance:
• Mucosa beneath denture is erythematous
with a well-demarcated border.
• Swabs from the mucosal surface may
provide a prolific growth, but biopsy shows
few candida hyphae in spite of high serum
and saliva antibodies to candida.
• Differential Diagnosis:
• Inflammatory papillary hyperplasia.

27. Chronic Hyperplastic Candidiasis
(Candida Leukoplakia)
• Etiology
• Oral Candidiasis lesions should be
considered as potentially premalignant.
Treatment should be directed toward
mucosa and Leukoplakia.
• Appearance
• Confluent leukoplakic plaques
characterized by Candida invasion of
oral epithelium with marked atypia.

29. Angular Cheilitis
• Etiology:
• Diminished occlusal vertical dimension
• Vitamin B or iron deficiencies
• Superimposed candidiasis
• Affects approximately 6% of General Population
• Appearance:
• Wrinkled and sagging skin at the lip commisures.
• Desiccation and mucosal cracking.

31. Angular Cheilitis
• Differential Diagnosis:
• Dry chapped lips.
• Basal cell carcinoma.
• Squamous cell carcinoma.

32. Angular Cheilitis
• Rx: Nystatin-triamcinolone acetonide
ointment.
Disp: 15 gm tube.
Sig: Apply to affected area after each
meal and qhs. Concomitant intraoral
antifungal treatment may be indicated.

33. Chronic Mucocutaneous
Candidiasis

34. Diagnostic Criteria
• C.F.U. in Candidiasis can vary from
1,000/ml to 20,000/ml.
• As an adjunct to saliva samples,
smears stained with PAS.
• Thus clinical manifestations, salivary
culture and stained smears are needed
to confirm a diagnosis of Candidiasis.

36. Management of Candidiasis

37. Candidiasis
• Rx: Nystatin oral suspension 100,000
units/ml.
Disp: 60 ml.
Sig: Swish and swallow 5 ml qid for 5 min.
• Rx: Nystatin ointment.
Disp: 15 gm tube.
Sig: Apply thin coat to affected areas after
each meal and qhs.
• Rx: Clotrimazole trouches 10 mg.
Disp: 70 trouches
Sig. Let 1 trouch dissolve in mouth 5 times
daily.

38. Candidiasis
• Rx for Dentures: Improve oral hygiene
of appliance.
• Keep denture out of mouth for extended
periods and while sleeping.
• Soak for 30 min in solutions containing
benzoic acid, 0.12% chlorhexidine, or
1% sodium hypochlorite and thoroughly
rinse.

39. Candidiasis
• Apply a few drops of Nystatin oral
suspension or a thin film of Nystatin
ointment to inner surface of denture
after each meal.

40. Rx for Refractory
Candidiasis
• Fluconazole 100 mg (20 tabs; 2 tabs
stat, then 1 tab daily).
• Itraconazole 100 mg (20 tabs; 1 tab bid).
• 2-4 weeks of Ketoconazole 200 mg (20
tabs, 1 tab daily).

45. DIAGNOSIS AND MANAGEMENT
OF XEROSTOMIA IN THE
ELDERLY PATIENT:

46. Salivary Gland Dysfunction
and Xerostomia (Dry Mouth)

48. XEROSTOMIA
• Xerostomia (dry mouth) is
defined as a subjective
complaint of dry mouth
that may result from a
decrease in the
production of saliva.

49. XEROSTOMIA
• It affects 17-29% of samples
populations based on self-reports
or measurements of salivary flow
rates.
• More prevalent in women.
• Can cause significant morbidity
and a reduction in a patient’s
perception of quality of life.

50. SALIVA
• It keeps the teeth healthy by
providing a lubricant, calcium
and a buffer.
• It also helps to maintain the
health of the gums, oral tissues
(mucosa) and throat.
• It also plays a role in the control
of bacteria in the mouth.

51. •It helps to cleanse the mouth of food
and debris.
•It provides minerals such as calcium,
fluoride, and phosphorus.
•It helps in swallowing and digesting
food.

52. •Lack of saliva will make the
mouth more prone to disease
and infection.
•Lead to a burning feeling.

53. Oral Dryness in the Elderly
0
10
20
30
40
50
60
70
80
90
Normal Radiotx Sjogren Drugs
Subjective sensation of oral dryness in the
elderly
%Population

55. Flow Rate of Saliva
0.0
0.1
0.2
0.3
0.4
0.5
20-39 yr 40-59 yr > 60 yr
Age
ml/min
unstimulated
stimulated

56. Antimicrobial Factors in
Human Whole Saliva
Non-immunoglobulin Factors Origin
Lysozyme Salivary glands, crevicular fluid (PMNs)
Lactoferrin Salivary glands, crevicular fluid (PMNs)
Salivary peroxidase Salivary glands
SCN- Salivary glands, crevicular fluid
H2O2 Salivary glands, crevicular fluid (PMNs),
bacterial and yeast cells
Myeloperoxidase Crevicular fluid (PMNs)
Cl- Salivary glands, crevicular fluid
Agglutinins, aggregating proteins Salivary glands
Histidine-rich polypeptides Salivary glands
Proline-rich proteins Salivary glands
Immunoglobulin Factors
Secretory IgA Salivary glands
IgA, IgG, IgM Crevicular fluid