11062021 Prof Hamam 1 Treatment of the common

11/06/2021 Prof. Hamam 1

Treatment of the common oral manifestations (Prof. M. Hamam) Oral and maxillofacial medicine. The basis of diagnosis and treatment ( Crispian Scully ) 11/06/2021 Prof. Hamam 2

Part 1 • Our universal aim should be to treat every as we would wish our families , indeed ourselves , to be treated. • Case history • Family history • Dental history (oral & maxillofacial medicine practice have systemic manifestations or medical problems ) • Medical history 11/06/2021 Prof. Hamam 3

Referral to a specialist Referral may be in indicated when the practitioner is faced with : • A complicated or serious diagnosis ( cancer , HIV , infection, pemphigus, Behcet disease ) • A doubtful diagnosis • A patient who has extra oral lesions or other indications of possible systemic disease. • A situation where therapy may not be straightforward and may require potent agents. • A situation where drug use needs to be monitored with laboratory or other testing ( e. g. for liver functional disturbances ) • A patient who needs access to an informed opinion or care outside normal working hours 11/06/2021 Prof. Hamam 4

• Should referral be required , it should always be in writing , giving a concise background to the referral , include : - • Referring clinician’s name , address, telephone , facsimile & e-mail. • Patient ‘s surname • Patient’ first name (s) • Patient’s date of birth • Patient’s full address and telephone , mobile phone. Facsimile & e-mail • Patient ‘s medical practitioner’s name , address and telephone , facsimile & e-mail 11/06/2021 Prof. Hamam 5

• • Urgency of referral ( real or perceived ) Reason for referral Relevant history & findings Provisional diagnosis Relevant medical history & social history Treatment already offered Any special needs 11/06/2021 Prof. Hamam 6

Psychological and sociological aspects of treatment. • Remember always that patients know whether the clinician cares well before they care whether the clinician knows all the answers. • Many orofacial condition are chronic & have no cure. • Few disorders the prognosis is poor , • Empowering patients allows them to take control of their lives and decisions affecting their wellbeing. • Such education and reassurance is always helpful ; supportive and understanding clinician is welcomed by the patient , their partner , and their family. • It is important to manage the patient as whole , in the context of their individual perceptions , aspirations , general health and social setting. 11/06/2021 Prof. Hamam 7

• Offer hope. Not all conditions can be cured , but most can be controlled or at least general improvement in oral health also help control symptoms in several other or orofacial disorders' • Work with the patient and family , and involve the patient in all decisions. • Discuss the condition , diagnosis and possible therapies with patient ( partner and family , provided the patient consents ). 11/06/2021 Prof. Hamam 8

• Warn of possible consequences ( good & bad ) of treatment or of no treatment. • Obtain express informed consent before an invasive procedure • Over advice on what patients themselves can do for their problems , ( support from family, partners, & friends ( e. g. alcohol, smoking , or other drugs ), disease support groups ( e. g. cancer , pemphigus , & sjogren syndrome ) other information sources ( patient inf. Sheets , the internet ). 11/06/2021 Prof. Hamam 9

Lifestyle changes • Tobacco products , areca nut products and alcoholic beverages , should be discouraged , especially in patients with oral mucosal diseases. • Sometimes , the cessation of these habits may lead to resolution of the condition. Diet and / oral hygiene may also need changing. • Preventive care • Oral hygiene. ( floss, toothbrush , toothpastes , anti-plaque agents , M. Ws ) • Caries prevention , diet , 11/06/2021 Prof. Hamam 10

Drug Treatment Always remember the following : Use the safest drugs. Check that the prescription is legible & that there is no history of allergy , Doses, contraindications , interactions & adverse reactions. Reduce drug doses when prescribing for children , the elder and patients Suffering from liver & kidney diseases. • A void drug use in pregnancy • • • 11/06/2021 Prof. Hamam 11

• A void giving aspirin to children under 16 years of age , because of the risk of Reye syndrome. • A void aspirin and non- steroid anti- inflammatory drugs ( NSAIDs) in patients with peptic ulcers, or bleeding tendencies( hemophilia or thrombocytopenia & those taking anticoagulant drugs, since they exacerbate bleeding. • Avoid metronidazole , and other antimicrobial in patients on warfarin , since they displace it from plasma proteins and increase bleeding. 11/06/2021 Prof. Hamam 12

• Avoid tetracycline in pregnancy or breast – feeding , as they cause tooth discoloration. • Avoid intramuscular injection in patients with bleeding tendencies , such as hemophilia or thrombocytopenia , and in those taking anticoagulant drugs , as hematoma can result , and take care with surgery. • Bisphonates , ( osteoradionecrosis ) 11/06/2021 Prof. Hamam 13

Prescribing for children • Doses of all drugs are much lower for children than for adults , always check against the recommended dose per unit body weight. • Some drugs ( e. g. diazepam ) are best avoid as they may have side effects • Oral preparations are preferable to inject able drugs. 11/06/2021 Prof. Hamam 14

Drugs and Food Absorption ▄ Most oral drugs are best given with or after food. ▄ Oral drugs that should be given at least 30 minutes before food , since their absorption is otherwise delayed , include : Erythromycin Paracetamol / acetaminophen Penicillin ( including ampicillin and amoxicillin ) Rifampicin Tetracycline ( except doxcycline ) ▄ Grapefruit juice disturbs the absorption and metabolism of some drugs and there fore , should be avoided by persons taking. Cyclosporine Calcium Terfendine 11/06/2021 Prof. Hamam 15

• Adverse reactions to drugs • Full medical history. • Patient should be warned if serious adverse reactions are liable to occur • ( e. g. systemic corticosteroids ) • After injection , there is small chance that anaphylactic shock may occur. 11/06/2021 Prof. Hamam 16

Agent used in the treatment of patient with oral disease • • Analgesics NSAIDs Aspirin Opioid and narcotics • Opioids are narcotics. They are controlled drugs and capable of causing addiction. • Opioids are analgesics used for moderate to sever pain. • Opioids may also cause constipation. Respiratory depression , nausea , drowsiness and urinary retention. 11/06/2021 Prof. Hamam 17

• Non- analgesic agents may be effective : • Anti depressants may control neuropathic pain. • Anticonvulsants may control neuralgia. • Capsaicin , an alkaloid derived from papers and used systemic or topically (post herpetic neuralgia ). • Topical analgesics ( mouth ulcers ). 11/06/2021 Prof. Hamam 18

CNS –active drugs • Hypnotics • Pain , anxiety or depression may cause insomnia. • Hypnotics may be contraindicated in elderly and in those with liver or respiratory disease. • Anticonvulsants. • They are used for the treatment of idiopathic trigeminal neuralgia. • It may cause blood dyscrasias or hepatic dysfunction , it may be helpful to monitor full blood counts and liver function. 11/06/2021 Prof. Hamam 19

Corticosteroids • Topical Corticosteroids( cream , gel, spray, ointment ) • Recurrent aphhthous stomatitis and oral lichen planus. • Cream can be bitter and gels can irritate. • The steroid needs to be in contact with the mucosa for 3 -minutes. • No eating or drink for 30 -min. • In patient using potent steroids for more than a month it is prefer to add an antifungal since candidasis may arise 11/06/2021 Prof. Hamam 20

• Intraregional corticosteroids • In the management of intractable local lesions such as erosive lichen planus ( prednisolone , , , , ) • Systemic immunosuppressant's include the following • Corticosteroids • Azathioprine • Cyclophosphamide • Mycophenolate • Leflunomide • Methotrexate 11/06/2021 Prof. Hamam 21

• Adverse effects can be serious and include the following • Infections , especially with viruses , fungi and mycobacterium ( tuberculosis ) • Lymphoproliferative disorders • Malgnancies ( lip carcinoma ) 11/06/2021 Prof. Hamam 22

Systemic Corticosteroids • Indications : • Bell’s palsy • Pemphigus • Sever or resistant oral ulceration in vesiculobulus conditions • Multisystem diseases , such as lichen planus , erythema multiforme or • Pemphigoid with oral , genital and cutaneous involvement. • Adverse effects : • Adrenocortical • Weight gain • Hypertension • Precipitation of diabetes • Cataract • Osteoporosis 11/06/2021 Prof. Hamam • Psychoses 23

• Dapsone ( steroid - sparing ). • • • • Antioxidant Interferes with neutrophil function ( adherence , chemotaxis , prostaglandin E 2 release , lysosomal enzyme ) Efficacy – 60 % , adverse effects – 25 %. Adverse effects include the following. Haematological ( haemolysis – agranulocytosis ) Liver function Renal dysfunction Hypersensitivity Headaches Photosensitivity Contraindications Glucose - 6 – phosphate dehydrogenase( G 6 PD ) deficiency Liver disease 11/06/2021 Prof. Hamam 24

Antimicrobials • Indications : • Cervical fascial space infections • Osteomyelitis • Odontogenic infections in ill or toxic patients ( if patient is immunocompromised ). • Acute ulcerative gingivitis. • Specific infections , such as tuberculosis and syphilis. • should be used in some instances of surgical conditions if they not respond to local measures ; • Pericronitis • Dental abscess • Dry socket 11/06/2021 Prof. Hamam 25

• Antimicrobial should be used for prophylaxis : • Infective endocarditis • Fractures • Patient with prosthetic joint replacements. ( rheumatoid arthritis ) 11/06/2021 Prof. Hamam 26

Antifungal therapy • • • Management of predisposing factors. Until there is no evidence of residual clinical lesions or symptoms and should be continued for at least 2 weeks more to reduce the risk of recurrence. Topical miconazole can enhance the effect of warfarin. Nystatin , ----- at least 4 times daily , 500 000 units for adults 100 000 units for children. Higher doses may be required in immunocomromised patients. Compliance can be a problem because of the taste but pastilles or suspensions often overcome this disadvantage. Nystatin if swallowed , may lead to GIT side effects ( nausea , vomiting & diarrhea ). Amphoten used as an oral suspension 100 mg / ml or lozenges 10 mg ( disadvantages fever , vomiting , renal damage 80% , bone marrow, cardiovascular toxicity ) Flucytosine ( 5 - fluorocytosine )50 -150 mg / kg / day. Miconazole ( topical treatment , angular stomatitis , chronic atrophic cand. 11/06/2021 Prof. Hamam 27

Antiviral therapy • Most antiviral achieve maximum benefit if given early in the disease • Most acute viral infections resolve naturally. • Antiviral resistance is now becoming a significant problem to immunocompromised persons , especially those with a sever immune defect. • Some antiviral active against herpes viruses 11/06/2021 Prof. Hamam 28

• • Antiviral active against herepes virus. Acyclovir : Valaciclovir is a pro-drug of acyclovir Combination therapy 11/06/2021 Prof. Hamam 29

Part 11 Treatment of the common oral manifestations (Prof. M. Hamam) • A. Red and White lesions: • Oral Cadidiasis, Hairy luekoplakia, Oral submucous fibrosis, Oral Lichen planus, Lichenoid reactions , geographic tongue, Leukoedema • B-. Acute Ulcerative lesions: Herpes semplex, Erythema multiforme, Hypersensitivity reactions, Aphthous ulcers. C. Chronic Ulcerative lesions: • Pemphigus Vulgaris, pemphigoids • D. Pigmented lesions: • Melanotic macule, melanotcytic nevus, Physiologic pigmentations, Drug induced melanosis, smoker's melanosis, Amalgam tatto. • E. Benign soft tissue lesions: • Fibromas, Pyogenic granuloma, Peripheral Giant cell granuloma. • F. Salivary glands diseases: • Sialolithiasis, Mucoceles, Xerostomia. • 11/06/2021 Prof. Hamam 30

A- Red and White lesions 1 - Oral Cadidiasis, 2 - Hairy luekoplakia, 3 -Oral submucous fibrosis, 4 - Oral Lichen planus, 5 - Lichenoid reactions , 6 - geographic tongue, 7 - Leukoedema • 1 - Oral Cadidiasis. 11/06/2021 Pseudomembranous candidiasis on the palate Prof. Hamam 31

Treatment • 1 - The underlying predisposing factors should be eliminated or corrected ( antibiotics, corticosteroid, poorly fitted dentures, systemic condition ) • • 2 -Antifungal agents include (7 -14 days) A-Nystatin B- Amphotericin C-Imidazole antifungal agents: (miconazole, ketoconazole, fluconazole, itraconazole ) • N. B. antifungal drugs should be maintained in acute oral lesions (2 weeks), & in chronic (4 weeks) 11/06/2021 Prof. Hamam 32

• • 3 - denture (relined , renewed) 4 - chlorohexidine rinse or gel 5 -Yoghuort and butter milk ( which containe culture of lactobacillus are useful adjuncts in the treatment of both oral and G. I. T moniliasis. 11/06/2021 Prof. Hamam 33

2 -Hairy Leukoplakia 1 - Incisional biopsy (HIV) 2 - Hairyleukoplakiaantiviral agents such as acyclovir. 3 - Asymptomatic, selflimited lesions in most cases. Medical referral. 34 11/06/2021 Prof. Hamam

3 -Submucous Fibrosis 1 - Discontinue habit, Fibrosis is irreversible. 2 - Stretching exercises +corticosteroid Clinical reexamination. ( is mandatory because approximately one third eventually develop squamous cell carcinoma 11/06/2021 Prof. Hamam 35

4 -Lichen Planus 1 - Incisional biopsy 2 -topical or systemic corticosteroids. 3 - Periodic clinical re-evaluation. 4 - Intra- lesional injection of steroid 5 - Antifungal drug 11/06/2021 Prof. Hamam 36

5 - Lichenoid reaction the lesion reversible by removing the causative factor Lichenoid reaction to dental amalgam and gold: white and erythematous lesions on the buccal mucosa 11/06/2021 Prof. Hamam 37

Lichenoid drug reaction • • This patient had an 8 -year history of a painful redwhite plaque on the lateral Border of the tongue. The plaque appears somewhat lichenoid, with radiating white line. The patient was on a B-blocker for hypertension for 9 -years and had these lesions continuously for 8 -years 11/06/2021 • Prof. Hamam Whtin 1 month of discontinuing the medication, the patient’slesions completely disappeared 38

6 - Geographic Tongue (Migratory Glossitis) Treatment: reassurance. 11/06/2021 Prof. Hamam 39

7 - Leukoedema Treatment: reassurance. 11/06/2021 Prof. Hamam 40

B- Acute ulcerative lesions 1 - Herpes Simplex infection 11/06/2021 Prof. Hamam 41

Treatment • 1 - Acyclovir No effect on normal cells but inhibits DNA replication in HSVinfected cells. • It is effective in first 72 hours • New antiherpes drugs are now available : - • Valacyclovir & Famciclovir → → it increased bioavailability allowing for effective treatment with fewer dose. . • Analgesic & Topical anaseth. ( mild case ) • 2 - Antibiotics are of no help in treatment of primary herps infection. 3 - Corticosteroid is contraindicated 4 - Vaccine ( in future; geno-therapy ). 11/06/2021 Prof. Hamam 42

2 -Erythema Multiforme Treatment : - Self-limiting ; supportive& directed toward elimination of ; A-Lesions : by topical steroid B-Pain : - by topical anesthesia C-Infection ; by tetracycline mouth rinse Bloody crusted appearance (The pathognomonic lesion ) or Iris lesion ; is a typical skin lesions contain petechiae in the center of the lesion Central bulla or pale clearing area surrounded by edema & bands of erythema 11/06/2021 Prof. Hamam 43

3 - hypersensitivity • • • • 1 - adrenaline ( anaphylactic shock , bronchial asthma and angioedema ) A- bronchial relaxation B- vasoconstriction C- decrase capillary permability ( reduce edema ) Within few minutes leading to : a- increase in blood pressure B- stimulation of heart muscle. Such action are life saving in particular with anaphylactic shock. Dose : 0. 5 ml ( 1/1000 conc ) I. M. or S. C Re-administrated after 5 minutes , if there is no improvement with maximum dose of 1. 5 ml Never to be given I. V to avoid ventricular fibrillation. 2 - Corticosteroids Anti-inflammatory 11/06/2021 Prof. Hamam 44

• 2 - Corticosteroids • Anti-inflammatory • 3 - Antihistaminics • Antihistaminics are of no value in emergency treatment since • A- they are slowly acting drugs • B- they antagonize one mediator only ( histamine ) • C- they restore the vasomotor tone without producing potential vasoconstriction • 11/06/2021 Prof. Hamam 45

Allergic stomatitis caused by acrylic resin Dentuer stomatits 11/06/2021 Prof. Hamam 46

4 - Aphthous ulcers • • • Tetracycline Mouth Bath * Mysteclin Capsule Tetracycline + nystatine dissolv. in 5 ml water *Mysteclin syrup Tetracycline + amphotericin It is used as mouth bath followed by topical application of steroid. * Phenol & sliver nitrate should be avoid. *Citrus fruits & highly spiced , , , , , * Soft laser Anti- TNF ( Trental ) Tetracy. mouth bath is benefit for (Herpatiform) 11/06/2021 Prof. Hamam 47

C- Chronic ulcerative lesions 1 - Pemphigus Vulgaris It cause blister & erosion of the skin & mucus membranes Pemphigus vulgaris: severe lesions of the skin of the face. • Pemphigus vulgaris: severe lesions of the skin of the face. Pemphigus vulgaris: ocular lesions. 11/06/2021 Prof. Hamam 48

Pemphigus vulgaris: erosions on the dorsum of the tongue. 11/06/2021 Pemphigus vulgar is: hemorrhagic cluster of bullae on the buccal mucosa Prof. Hamam 49

Treatment • Systemic corticosteroid (1 -2 mg/kg/d ) • combination topical + systemic steroid therapy • Plasmapheresis is useful in refractory patient to corticosteroid (it can reduce autoantibody level by 80% within 3 - weeks ). 11/06/2021 Prof. Hamam 50

2 -Benign Mucous Membrane Pemphigoid ocular- cicatricial pemphigoid Clinical features Age: - 50 -60 Sex: - Female Site : - trachea , larynx , esophagus →→ →stenosis →scaring →difficulty in breathing & swallowing Eyes : - shallow conjunctiva erosion →scar , corneal damage → eye blindness Skin : - skin lesions following the appearance of mucosal lesions. around , scalp (bullae & ulcerated crusted lesions. 11/06/2021 Prof. Hamam 51

Oral manifestations Desqumative gingivitis ; The epithelium can often be stripped away with ease , leaving raw bleeding denuded surface , Nikolsky’s sign is positive Healing with scar formation Course , restricted to one site ( mouth) For several years. It is characterized by remission & exacerbation 11/06/2021 Prof. Hamam 52

Treatment • 1 - Gingival involvement • Oral hygiene reinforcement; scaling &root planning • 2 - symptomatic disease • Topical application of potent steroid 2 -3 t. d. • Intraregional steroid injection may be carried out at few weeks interval. • 3 - Dapsone ( anti-inflamatory effect) 11/06/2021 Prof. Hamam 53

D-Pigmented lesions 1 -Oral focal melanotic macule of the gingiva. This lesion is the oral counterpart of the ephelis biopsy specimen should be obtained to secure a definitive diagnosis. The oral melanotic macule is innocuous, does not represent a melanocytic proliferation, and does not predispose to melanoma. Once it is removed, no further surgery is required. 11/06/2021 Prof. Hamam 54

2 - Melanotic nevus Biopsy is necessary for diagnostic confirmation since the clinical diagnosis includes many other focal pigmentations, such as melanotic macule, melanoma, and amalgam tattoo. Simple excision is the treatment of choice. Nevocellular nevus of the palate. The nevus is raised and gray brown. 11/06/2021 Prof. Hamam 55

3 - Drug-Induced Melanosis drugs can induce oral mucosal pigmentation hard palate. Drugs : quinoline, hydroxyquinoline, and amodiaquine antimalarials. These medications have also been used in the treatment of autoimmune diseases. Minocycline, used Perioral melanosis (melasma) in a young woman in the treatment of taking birth control pills. acne, can also produce oral pigmentation 11/06/2021 Prof. Hamam 56

• . The pigment is not confined to oral mucosa and is also encountered in the nail bed and on the skin. • oral contraceptives and pregnancy are occasionally associated with hyper pigmentation of the facial skin, particularly in the periorbital and perioral regions • . This condition is referred to as melasma or chloasma. Endocrine disease should be excluded by appropriate laboratory studies when oral or facial nonphysiologic melanosis is encountered. • The cause is unknown, and the pigment may remain for • quite some time after withdrawal of the incriminated drug. 11/06/2021 Prof. Hamam 57

4 - Physiologic Pigmentation This type of pigmentation is persistent and symmetrical, and clinically presents as asymptomatic black or brown areas of varying size. The gingiva are most commonly affected, followed by the buccal mucosa, palate, and lips. . The pigmentation is more prominent in areas of pressure or friction, and usually becomes more intense with increasing age. . 11/06/2021 Normal pigmentation of the gingiva. Prof. Hamam 58

5 - Smoker’s Melanosis Diffuse macular melanosis of the buccal mucosa, lateral tongue, palate, and floor of the mouth is occasionally seen among cigarette smokers. Diffuse melanosis of the buccal mucosa in a cigarette smoker (smoker’s melanosis). 11/06/2021 Prof. Hamam 59

6 - Amalgam Tattoo the most common source of solitary or focal pigmentation in the oral mucosa is the amalgam tattoo. . The buccal mucosa, gingiva, or palate Since amalgam tattoos are innocuous, their removal is not required, particularly when they can be documented radiographically. Alternatively, biopsy is recommended when a gray pigmented lesion suddenly appears or when such a lesion arises distant from any restored teeth; the differential diagnosis must include nevi and melanoma in such instances 11/06/2021 Amalgam tattoo of the buccal mucosa. The lesion appears gray black. Prof. Hamam 60

E- Benign soft tissue lesions Giant-cell fibroma of the tongue. 11/06/2021 Prof. Hamam Fibroma of the palate 61

Pyogenic Granuloma Definition Pyogenic granuloma is a common tumorlike granulation tissue overgrowth of the oral tissues in reaction to mild irritation Treatment : Surgical excision. 11/06/2021 Pyogenic granuloma of the gingiva. Pyogenic granuloma on the dorsum of the tongue. Prof. Hamam 62

Peripheral Giant-Cell Granuloma Definition Peripheral giant -cell granuloma is a relatively uncommon reactive tumor of the oral cavity. Treatment Surgical excision. Peripheral giant-cell granuloma: early lesion on the gingiva. 11/06/2021 Prof. Hamam 63

F- Sialolithiasis (Salivary Stones) The submandibular gland is the most common site TREATMENT During the acute phase, therapy is primarily supportive. Standard care includes analgesics, hydration, antibiotics, and antipyretics, as necessary. In pronounced exacerbations, surgical intervention for drainage is sometimes required. • Stones at or near the orifice of the duct can often be removed transorally • by milking the gland, but deeper stones require surgery. • • • 11/06/2021 Prof. Hamam 64

• Once the acute phase subsides, surgical treatment can be performed. • Location within the duct determines the type of surgery required for removal of the stone. • If the stone lies in the intraglandular portion of the duct, it is recommended that the entire gland be removed. • As much as 75% of normal function can return if the stone can be removed from within the duct, without entering the body of the gland. 11/06/2021 Prof. Hamam 65

Mucoceles “Mucocele”is a clinical term that describes swelling caused by the accumulation of saliva at the site of a traumatized or obstructed minor salivary gland duct. Mucoceles are classified as extravasation types and retention types. A large form of mucocele located in the floor of the mouth is known as a ranula. Treatment. The treatment of choice for mucoceles is surgical excision. Removal of the associated salivary glands is essential to prevent recurrence. Aspiration of the fluid only does not provide long-term benefit. Managing of mucoceles can be difficult because surgical removal may cause trauma to other adjacent minor salivary glands and lead to the development of a new mucocele. Intraregional injections of corticosteroids have been used successfully to treat mucoceles. 11/06/2021 Mucocele. Mucous extravasations phenomenon involving the lower lip Prof. Hamam 66

TREATMENT OF XEROSTOMIA • Treatment that is available for the dry mouth patient can be • divided into four main categories: • (1) preventive therapy, • (2)symptomatic treatment, • (3) local or topical salivary stimulation, • (4) systemic salivary stimulation. Effective treatment • of an underlying systemic disorder associated with salivary • gland dysfunction may correct the salivary complaint as well 11/06/2021 Prof. Hamam 67

• Preventive Therapy • The use of topical fluorides in a patient with salivary gland • Hypo function is absolutely critical to control dental caries. • There a number of oral rinses and gels available. • Patients should be cautioned to avoid products containing • alcohol, sugar, or strong flavorings that may irritate sensitive dry mucosa. • Moisturizing creams are important. 11/06/2021 Prof. Hamam 68

Salivary Stimulation • LOCAL OR TOPICAL STIMULATION • Several approaches are available for stimulating salivary flow. • Chewing will stimulate salivary flow effectively, as will sour and sweet tastes. The combination of chewing and taste, as provided by gums or mints, can be very effective in relieving symptoms for patients who have remaining salivary function. • Patients with dry mouth does not use products that contain sugar as a sweetener, due to the increased risk for dental caries in this group. • Electrical stimulation has also been used as a therapy for salivary hypo function but has been inadequately investigated clinically. • A device that delivers a very low- voltage electrical charge to the tongue and palate has been described although its effect was modest in patients with dry mouth. 11/06/2021 Prof. Hamam 69

• SYSTEMIC STIMULATION • Four have been examined extensively in controlled clinical trials; these are bromhexine, anetholetrithione, pilocarpine hydrochloride (HCl), and cevimeline HCl. 11/06/2021 Prof. Hamam 70