SALIVARY RESERVOIR DESIGNS FOR PATIENTS WITH XEROSTOMIA: A REVIEW

Prem  Bhushan1,  Meena  A.  Aras1,  Vidya  Chitre1,  Ivy  Coutinho1,  Aradhana  Nagarsekhar1,  Ashwin  Mysore1
1  Department  of  Prosthodontics,  Goa  Dental  College  and  Hospital,  Bambolim,  Goa,  India

CORRESPONDING  AUTHOR:  p21bhushan@gmail.com

ABSTRACT

Aim:   The present paper aims to review the literature available on various approaches to salivary reservoir
designs, the functional aspects, cleansibility, type of attachments used, and different techniques used for the
fabrication of salivary reservoirs in patients suffering from xerostomia.

Material  and  Methods:  A search in the National Library of Medicine’s Pub Med database, Google search and
Science Direct was performed to include all case reports and reviews on prosthodontic rehabilitation of
dentulous/partially edentulous/edentulous patient with xerostomia.

Results:  Out of the 35 articles found in the database search, 18 articles were included based on the designs they
adopted for fabrication of salivary reservoirs.

Conclusions:   The various designs available in literature enable an operator to choose the most suitable
reservoir design based on specific patient requirements. Innovations in reservoir design promise a more
customized prosthesis for every patient. Further research and innovation will enable increasingly efficient
salivary substitute delivery systems for the xerostomic patient.

KEYWORDS:  salivary reservoir, denture reservoir, xerostomia, functional reservoir, attachment for reservoir

INTRODUCTION contributions of unstimulated saliva are candidosis; burning mouth; sore tongue
20% from parotid, 65% from (glossodynia); difficulties with speech,
  Saliva is one of the most submandibular, 7% to 8% from mastication, and swallowing; altered
important components of the sublingual, and less than 10% from taste sensation (dysgeusia); and halitosis
stomagnathic system and is secreted numerous minor glands2. The accepted are either due to decreased salivary flow
from the exocrine salivary glands. It is of normal flow for unstimulated saliva is or alteration in salivary composition1.
great importance for the maintenance of anything above 0.1 ml/min; any Xerostomia is the subjective symptom or
health and function of the system. Mean unstimulated flow rate below 0.1 ml/min sensation of dry mouth; defined as
daily salivary output ranges from 500 to is considered to be hypofunction3. dryness of mouth due to lack of normal
1500 ml and the average volume of saliva Many of the signs of oral secretion of saliva1.
present in the oral cavity is imbalances like increased caries   Causes of xerostomia can be
approximately one ml1. The percentage incidence; susceptibility to oral categorized into: (1) developmental
 Bhushan et al • Journal of Research in Dentistry 2016, 4(2):51-57

disturbances in the glands; (2) water or oral functions and should be simple to salivary reservoir - reservoir where the
metabolite loss; (3) iatrogenic causes use and easy to clean4. patient can control the release of saliva by
including medication and radiotherapy; functional movement of the structures of
(4) systemic disease including sjogren LITERATURE REVIEW the oral cavity like movement of tongue4,
syndrome, diabetes, etc; (5) local factors s u c k i n g5 a n d s w a l l o w i n g6,7; ( b )
CLASSIFICATION
including smoking, mouth breathing nonfunctional salivary reservoir -
etc1,2.   In literature a classification for reservoir where release and flow rate are
salivary reservoirs does not exist. A
The treatment options of not under the control of patient (eg:
classification of salivary reservoir is
xerostomia are categorized into: (1) release of saliva due to gravity only).
proposed here based on the designs
general management (etiological This article reviews in English
found during the search, to simplify
management) which focus on treating literature published from 1984- 2014 with
understanding and communication.
the main etiology of xerostomia which various approaches for the fabrication of
1. Based on the arch into which the
can be drugs, low salt diets, radiotherapy, a salivary reservoir.
salivary reservoir is incorporated: (a)
etc; (2) preventive measures which A search in the National Library
maxillary salivary reservoir; (b)
include frequent checks for maintenance of Medicine’s Pub Med database, Google
mandibular salivary reservoir.
of stomagnathic system (eg: frequent scholar and Science Direct was
2. Based on cleansibility of salivary
dental visit, fluoride application, etc); (3) performed to include all case reports and
reservoir: (a) cleansable salivary reservoir
measures to increase salivary flow reviews on prosthodontic rehabilitation
- reservoir which has a removable lid and
including sialogogues; (4) management of dentulous/edentulous patients
can be cleaned from inside under direct
of underlying systemic disease; (5) use of suffering from xerostomia where
vision; (b) non-cleansable salivary
saliva substitute which are categorized treatment included incorporation of
reservoir - reservoir which cannot be
into glycerine and lemon based, salivary reservoir into prosthesis. The
cleaned under direct vision as the lid is
carboxymethyl cellulose based, and inclusion and exclusion criteria were
permanently fixed and cannot be
mucin based; (6) use of oral lubricating described in table 1.
separated.
device which includes salivary reservoirs.
3. Based on functional aspect of
An ideal salivary reservoir is a
stomagnathic system: (a) functional
device which should not impede normal

Table 1. Inclusion and exclusion criteria.

Inclusion criteria Exclusion criteria

PubMed indexed articles Non PubMed indexed articles
Written in English language Written in language other than English
Full text availability Abstract

Out of the 35 articles found in DISCUSSION functional salivary reservoir category

the database search, 18 articles were a n d t w o9,21 w e r e f o u n d i n
Out of the eighteen articles
included based on whether they nonfunctional salivary reservoir
found in literature, three designs5-7
described new designs for fabrication category.
were found to be functional salivary
of salivary reservoirs. The key words
reservoirs while thirteen designs8-11
used for the search were salivary FUNCTIONAL SALIVARY RESERVOIRS
were found to be nonfunctional
reservoir, denture reservoir and Have an advantage over
salivary reservoirs in the complete
xerostomia. nonfunctional salivary reservoir as
denture category12-18. In removable cast controlled release of saliva can be
partial dentures, three designs8,19,20
RESULTS a c h i e v e d4-7 b y t h e f u n c t i o n a l
were found to be in the nonfunctional
movements of oral cavity like
The various articles are category, while in removable partial 4 5
movement of tongue , sucking and
categorized as follows (Table 2). dentures one design4 was found in

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swallowing6,7. Upadhyay et al.6 had leads to less outlet clogging and helps have been used for the fabrication of
used swallowing movements for the in sustained release of saliva6. These the lid of the reservoirs.
release of salivary substitute which articles report that flexible materials

Table 2. Articles used in the review.

COMPLETE DENTURE RESERVOIRS
Salivary Filling of Drainage of
Functional/ non- Cleansibility Reservoir space
Author Arch Type of attachment substitute salivary salivary Remarks
functional maintained by
used reservoir reservoir

Beeswax was used for palatal contouring, metal

Two holes of 1.5
base of Co-Cr was used, which was 0.45mm
mm in diameter 1 hole in the
thick in center and 1mm in the region where
Mechanical interlocking Optosil (Bayer, in anterior and center of the
met the acrylic. Latex membrane (Penrose
Vissink et al[5] Maxillary functional Cleansable between Co-Cr plate and Leverkuse, West N.A posterior region acrylic resin lid
drain, Argyle, Tullamore, Ireland) was fixed
acrylic Germany) of metal base (polished
with cyanoacrylate at the opening, a punch hole
(intaglio surface)
was made in it for the flow of saliva by sucking
surface)
activity

Saliva
1 mm in the 1 mm in Acrylic based resilient liner((Permasoft;
Both components Orthana(AS
Fixed with anterior part anterior part Dentsply, New Delhi, India) was used for
Upadhyay et al [6]
Maxillary functional Non-cleansable were fabricated Pharma,
autopolymerising resin (lowest part of (lowest part of functional flow of saliva, activated by tongue
separately Andover,
reservoir floor) reservoir floor) movements
UK)

Functional palatogram assessment using

1 mm releasing tissue-conditioning material (Visco-gel;
A mixture of 50%
By removing hole at the most Dentsply Ltd., Weybridge, UK) lid: 2-mm thick
Shah et al[7] Maxillary functional Cleansable Friction lock attachment pumice and 50% N.A
the flexible lid dependent flexible BIOPLAST(Scheu Dental
plaster
point on the lid GmbH,Germeny) material used for functional
flow of saliva

3 holes in 3 holes in
Xero-lube
anterior region anterior region
(Scherer
Fixed with along the outer along the outer Co-Cr palate and meshwork was used to reduce
Toljanic et al[8] Maxillary Non fuctional Non- cleansable Plaster Laboratorie,
autopolymerising resin edge of cap with edge of cap overall thickness of the denture base
Inc., Dallas,
number 1 round with number 1
Texas).
bur round bur
Two holes of 1.5
Mucin (Salivamm in diameter Co-Cr plate was 0.45mm thick in the center and
0.1-0.2 mm hole
Mechanical interlocking Optosil (Bayer, Orthana, in anterior and 1mm at the junction of acrylic resin denture
which was 5mm
Vissink et al[9] Maxillary Non fuctional Cleansable between Co-Cr plate and Leverkuse, West Orthana Ltd., posterior areas base and Co-Cr. Palatal contouring was carried
palatal to the
acrylic Germany) Copenhage, of the metal out by functional movement of the tongue and
anterior tooth
Denmark). base (intaglio recorded by soft wax
surface)
Mechanical interlocking By seepage of
By sliding open Lid fabricated with flexible denture material
Singh et al[10] Maxillary Non fuctional Cleansable with 1mm slot below the N.A wetmouth salivary
the lid (Lucitone).
polished surface of palate substitute
Escape path was
0.5 mm hole in
made by using
the intaglio 0.45 mm Co-Cr intaglio surface with vertical
Rhein 83 attachment of Modeling clay Wetmouth a cellophane
Debnath et al[11] Maxillary Non fuctional Cleansable surface of the wallsfor the reservoir and spheres for OT caps
2mm diameter (Jingjing, china) ICPA sheet in the
metallic were cast together
posterior part of
framework
the lid
Denture made in
0.1 -0.2 mm on The stainless steel metallic track was 25 mm
Sliding frictional lock two parts by using By sliding the
the lingual long, 2.8 mm high, and 7 mm wide at the base,
between the metal track interchangeable posterior tooth
Vissink et al[9] Mandibular Non fuctional Cleansable N.A surface of the and 4.5 mm wide at the top. Lid on top of it was
and block of acrylic resin flask and fix with section on its
midline of made with a block of acrylic resin that slid into
posterior teeth autopolymerising metallic track
denture the metal track
resin
Magnets, two 4 mm
cobalt samarium magnets
KY jelly
[Magnet Development 1.3 mm release The magnets used had a breakaway force of 400
(Johnson and By removing
Ltd., Swindon, England] Mixture of hole in the fit gm.
Sinclair, Frost and Johnson Ltd. the occlusal lid
Mandibular Non fuctional Cleansable posteriorly for 80%plaster and surface, one in Magnetic force is lost under shear force so to
Walter[12] Maidenhea, from the
attachment and one 1.2 20%pumice each 2nd avoid that,an anterior rod was used which
Berkshire, reservoir
mm stainless steel strut premolar region prevents the shearing force
England)
anteriorly for bracing
action
Three Space for reservoir
double-toothed LegoTM was cut in recall
Mendoza and (LEGO, LEGO Korea Co appointment by By separating 0.5 mm
Tomlinson[13] Ltd, maintaining a the two parts of diameter on the
Mandibular Non fuctional Cleansable
Seoul, Korea) blocks were minimum the split inferior aspect
And Dabas et al[14] used, one in anterior thickness of 2mm denture of lingual flange
region and two in of acrylic for
posterior region reservoir walls
3 outlet holes on
Labially in
each side in
Stainless steel press on between two
Wet Mouth, retromylohoid
Burhanpurwala et al[15] Mandibular Non fuctional Cleansable button in the molar Putty central incisor
ICPA region of
region of diameter of
diameter of 26
19 gauge needle
gauge needle

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six metal rods 3mm in

length and 2mm in The hole is
diameter having a groove Lingually in made by ♯8
at one end for retention between two
Pattanaik and
and were made of Ni-Cr central Incisors straight fissure Precision is required to place the metal rods
pattanaik[16] Cleansable Clay Methyl bur on the
Mandibular Non fuctional alloy (Bellabond Plus, in the upper parallel to each other and adequate acrylic is
Putty (ladda et al) cellulose inferior surface
Bego, Bremen, Germany) section necessary around the metal rod
Ladda et al[17] of the lingual
and placed parallel to containing the
each other while aspect on either
teeth
5 metal rods were used by side
ladda et al
Space for reservoir
The
was made
Six mechanical Customized reservoirwas Lingual aspect
rectangule in
Hallikerimath and jain[18] Mandibular Non fuctional Cleansable interlocking by custom artificial filled with the of the base of
premolar to molar
made attachments saliva help of a the reservoir
region using
syringe
straight fissure bur
A hollow plastic
0.2 mm
Fixed with cap and the hub
diameter in
autopolymerising resin Modeling clay Wetmouth of 2ml
Debnath et al[11] Mandibular Non fuctional Non-cleansable anterior lingual
using 3 V shaped notches ( Jingjing, china) ICPA disposable
aspect of the
as reference syringe was
denture
used
REMOVABLE CAST PARTIAL DENTURE
Xero-lube (Scherer
3 holes in the anterior 3 holes in the anterior
Fixed with Laboratories, Inc., Intaglio surface was Co-Cr and the lid was
Toljanicet al[8] Maxillary Non fuctional Non- cleansable Plaster region with no 1 round region with no 1 round
autopolymerising resin Dallas, of autopolymerising resin
bur bur
Texas)
2 mm in diameter in
2 holes of 1mm
Stainless steel snap Xero-Lube the mid palatal region The lid was fabricated with
Agarwal et al[19] Maxillary Non fuctional Cleansable Plaster diameter in premolar
button of the polished surface autopolymerising resin
region
of the reservoir
Precision attachment- 2 holes of 0.7 mm
The denture was filled
5mm ₓ 2.8 mm was used diameter in the Palatogram analysis was carried out with
Modgi et al[20] Maxillary Non fuctional Cleansable Lab putty E-saliva with the help of a
( MINICON V 37580, posterior region of tissue conditioner
syringe
BEGO GERMANY) reservoir
REMOVABLE PARTIAL DENTURE

Two holes of 1.5

Mucin (Saliva
Mechanical mm diameter in 0.1-0.2 mm, location of
Optosil (Bayer, Orthana, Co-Cr plate was 0.45mm thick in center and
interlocking the anterior and the hole was 5mm
Vissink et al[9] Maxillary Non fuctional Cleansable Leverkuse, West Orthana Ltd., 1mm at the junction of acrylic resin and C0-
between Co-Cr posterior palatal to the anterior
Germany) Copenhage, Cr.
plate and acrylic position of the tooth
Denmark).
metal base

Two layers of EVA

resin was pressed
with water
EVA resin (EVA resin (Erkoflex)) Erkodent,
dispensable
Holes of 2 mm Erich Kopp GmbH, Siemensstrasse 3,D —
Frost et al[21] Maxillary Non fuctional Non cleansable medium like Plaster and pumice K-Y jelly
diameter 72285 Pfazgrafenweiler, Germany) was used
mixture of plaster
for the fabrication of the prosthesis
and pumice
sandwiched in
between

A ball valve, with an

opening of 4-5 mm
Oral Balance gel By locating diameter 6mm
Functional reservoir in which patient can
Fixed with (Laclede Inc., device and diameter stainless steel
control the release of saliva through the ball
Kam et al[4] Maxillary Fuctional Non cleansable autopolymerising Dental stone Rancho syringe specially ball attached with 0.7
valve opening using tongue movement and
resin Dominguez, CA, designed for mm stainless steel wire
intra oral pressure
USA) refilling with an elastic
diaphragm to control
flow

Upadhyay et al.6 preferred to time but requires special equipment xerostomic patients and other patients
use an acrylic resin based heat for its fabrication. Vissinik et al.5 used predisposed to infection, especially to
polymerizing liner material which they rubber dam material which allows slow candidial infection. A reservoir can be
claimed can be polished, has high release of saliva but its integration onto rendered cleansable by separating two
durable bond strength, and is less the prosthesis is technique sensitive parts of the reservoir, so that it’s
susceptible tocolonization with and durability is questionable. cleaning can be performed under
candida albicans22. However the main direct vision. Some designs in
disadvantage of this material is that it CLEANSIBILITY literature advocate cleaning by forcibly
loses its resiliency in 12-18 month and Cleansibility of a reservoir injecting a cleaning agent from one
requires replacement6. Shah et al.7 used becomes an important consideration as opening and discharging it from the
a 2mm thick ethylene vinyl acetate, it can harbor pathological other, but the effectiveness of this type
which does not lose its resiliency over microorganisms particularly in of cleaning of the reservoir is less than

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adequate at best as the operator/ attachment component is critical to manual dexterity to separate and rejoin
patient does not have direct access to achieve, increased costs and the the two segments of the split denture,
clean all the surfaces of the reservoir possible encroachment into the tongue accurate reseating of the processed
thoroughly especially with the presence space especially in a lower prosthesis denture becomes difficult if large
of particulate matter and biofilms which may adversely affect speech and undercuts are present so case selection
within the cavity. comfort. becomes important while selecting this
type of attachment system, only cases
ARTIFICIAL SALIVA Figure 1. Cross section of maxillary functional of sufficient vertical dimension and
Ideally saliva substitutes reservoir with mechanical attachment. thickness are suitable for these
should be pleasant to taste, nontoxic, attachment13 and they also cannot be
non-addictive, economical and must used universally for all cases (Figure 3).
exhibit good wetting of the tissue
surface of denture23. Studies have Figure 2. Magnetic attachment with anterior

shown that in the absence of strut.

thickening agent in artificial saliva, the

use of water to moisten and lubricate
the oral mucosa is less effective23,24
when used inside a reservoir. Therefore
the use of artificial saliva in salivary
reservoirs is recommended. 3. Magnets 12 : used cobalt
Artificial saliva substitutes are samarium magnets which were 4mm
broadly categorized into two groups in diameter and had a breaking force of
carboxymethyl cellulose based and 400 gms. The main problem with
mucin based, though mucin based magnets as attachment is the loss of
saliva substitutes have shown better magnetic bonding, which occurs under
wettability of oral tissue than a shearing load. It also requires
5. Stainless steel press on
carboxymethyl cellulose based artificial exhaustive laboratory steps, results in
buttons 15,19
: these are buttons that are
saliva but because of their porcine or and precision for proper placement, so
adapted from textile industry. Their
bovine origin, mucin based artificial care must be taken to eliminate the
precise fit with these is questionable at
saliva are likely to be objectionable in shearing force which results in a
best and seepage of saliva may occur 15,
some parts of world23. separation of the two parts of the
stainless steel press on buttons need
denture. In the design described by
replacements as they loosen with time
ATTACHMENTS Sinclairone anterior strut was used to
17
and their resistance to corrosion is
1. Mechanical interlockin prevent this shearing force. While
not known.
5,7,9,10,18
: the advantages of these selecting a magnet for this application
6. Metal rods 16,17: of Ni-Cr alloy
attachments include reduced costs and one should ensure that the bonding
have been used as attachments which
reduced weight of prosthesis, but the system is strong enough to withstand
have a groove at one end that fits a
disadvantages are that they are very the parting forces of sticky food
fabricated counterpart on the denture.
technique sensitive. Precision is substances. Iron neodyum boron
Using them as attachments requires at
required for the precise fit and they magnets are also available in small
least two mm of acrylic around each,
tend to have lengthy and complicated sizes and can produce a greater
but giving two mm of acrylic around all
lab procedures (Figure 1). attachment force12 (Figure 2).
metal rods ultimately leads to a
2. Rhein 8311: the advantages of 4. Double tooth lego blocks13,14:
decrease in reservoir space.
this attachmentis its availability in a it is known that it is important to place
7. Precision attachment 20 :
variety of intensities of retention, but them parallel to each other when more
these are frictional grip slide
disadvantages are increased weight of than one block is used for efficient use,
attachments.Male and female
the prosthesis, parallelism of other disadvantages include need of

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components make it precise and it For a mandibular salivary 7. Shah RM, Aras MA, Chitre V. An
utilizes less space thus providing more reservoir it is better to determine the innovative and simple approach to
volume for the reservoir. potential area for the salivary reservoir functional salivary reservoir fabrication. J
Disadvantages include the cost and by carrying out a neutral zone Prosthodont 2014;00:1-4.

difficulties is achieving parallelism recording. In cases of split dentures it 8. Toljanic JA, Zucuskie TG. Use of palatal
between attachments. is important to keep a minimum of reservoir in denture patients with
three mm acrylic below the artificial xerostomia. J Prosthet Dent 1984;52:540-4.
Figure 3. Lego® block attachment with reservoir teeth and two mm acrylic for the
space. reservoir wall for strength. In 9. Vissink A, Gravenmade EJ, Panders AK, et
al. Artificial saliva reservoirs. J Prosthet
mandibular salivary reservoirs
Dent 1984;52:710-5.
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Selection of attachments depends on 10. Singh Y, Saini M, Siwach A, et al.
the personal choice and experience, the Management of a post-radiotherapy
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made at the time of acrylization as Gerodontol 2012;29:e1172–5.
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11. Debnath N, Gupta R, Devi AS, et al.
rough internal surfaces which may be
Prosthodontic rehabilitation of an
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bacterial colonization. saliva reservoir in complete denture. Int J
Prosthodont Restor Dent 2013;3:37-41.
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