Impact of xerostomia on dental treatment outcomes: a systematic review

Impact of xerostomia on dental treatment outcomes: a systematic review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Impact of xerostomia on dental treatment outcomes: a systematic review Sishir Poudel, Prakash Kafle, Prativa Pandey, Pravin Thapa, Anup Baral, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7614524/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Feb, 2026 Read the published version in BMC Oral Health → Version 1 posted 9 You are reading this latest preprint version Abstract Background Xerostomia, commonly caused by medications, radiotherapy, or Sjögren’s syndrome, impairs saliva’s protective functions and increases risk of caries, restoration failure, prosthesis complications, and peri-implant bone loss. However, its overall impact on dental treatment outcomes has not been systematically reviewed. Methods A systematic review was conducted following PRISMA guidelines. Electronic databases were searched, and studies evaluating the impact of xerostomia on dental treatment outcomes, including restorations, implants, prostheses, and periodontal therapy, were included. Data extraction was performed in duplicate, and risk of bias was assessed using RoB 2.0 for randomized trials and ROBINS-I for non-randomized studies. Certainty of evidence was graded using the GRADE approach. Results Sixteen studies were included in the review. Implant survival in xerostomic patients was generally high (> 90%) but slightly lower in those with radiation-induced xerostomia. Restoration longevity was consistently reduced, with higher failure and recurrent caries rates in Sjögren’s syndrome and post-radiotherapy patients. Limited evidence suggested no major differences in periodontal treatment response, while no eligible studies directly assessed denture retention. Overall, most studies were small, heterogeneous, and at moderate to serious risk of bias. Conclusions Xerostomia reduces restoration longevity and may affect periodontal therapy, while implants generally show good survival. Evidence is limited and biased, highlighting the need for preventive care and stronger clinical studies. Figures Figure 1 Introduction Xerostomia, commonly referred to as dry mouth, is the subjective sensation of oral dryness and is frequently associated with reduced salivary flow (hyposalivation) [ 1 ]. Notably, some individuals experience xerostomic symptoms despite having normal salivary function, a condition described as “symptomatic” or “pseudo” xerostomia [ 1 ]. The condition most often arises from diminished salivary secretion, which compromises the natural lubrication of the oral mucosa and affects overall oral health [ 2 , 3 ]. Xerostomia can affect people of all ages but is particularly common among postmenopausal women and older adults [ 4 ]. The causes of xerostomia are diverse. Medication-induced salivary dysfunction is the most frequent etiology, with drug classes such as anticholinergics, antidepressants, antipsychotics, diuretics, antihypertensives, sedatives, muscle relaxants, opioids, NSAIDs, and antihistamines often implicated [ 2 ]. Radiation therapy for head and neck cancers almost universally leads to xerostomia, as exposure of the parotid glands to doses above 24–26 Gy causes irreversible glandular damage and long-term hyposalivation [ 2 ]. Another well-recognized cause is Sjögren’s syndrome, an autoimmune disease that destroys salivary and lacrimal glands, most often affecting women over the age of 40 [ 2 ]. Other systemic conditions such as diabetes mellitus, systemic lupus erythematosus, thyroid disorders, HIV/AIDS, end-stage renal disease, and graft-versus-host disease, as well as lifestyle factors including chronic mouth breathing and dehydration, may also contribute [ 2 ]. Saliva plays a vital role in oral health, with daily secretion ranging from 0.5 to 1.5 liters and containing electrolytes, proteins, enzymes, and antimicrobial agents [ 5 ]. It facilitates lubrication, mastication, swallowing, and digestion; contributes to buffering and remineralization; maintains a balanced oral microbiome; and supports tissue repair [ 5 ]. When salivary flow is compromised, patients are predisposed to complications such as mucosal irritation, infection, oral dysbiosis, and impaired wound healing [ 5 ]. These pathophysiological changes have important implications for dental care. In restorative dentistry, xerostomia accelerates secondary caries and increases restoration failure rates, with studies noting reduced survival of glass ionomer and composite fillings in affected patients [ 6 ]. In prosthodontics, the absence of salivary lubrication impairs denture retention and comfort and also periodontal therapy may be less effective due to reduced mucosal defense, while in oral surgery, healing complications such as dry socket are more frequent, particularly among patients with comorbidities like diabetes [ 7 , 8 ]. Additionally, peri-implant bone resorption may be accelerated by heightened mucosal inflammation and osteoclast activity in xerostomic patients [ 9 ]. Reduced saliva flow or altered saliva quality can harm teeth, hinder bone integration, and affect peri-implant health [ 10 ]. In scleroderma and Sjögren’s syndrome, this often leads to greater bone loss and soft tissue changes around implants [ 10 ]. Despite the growing body of literature describing these effects, there remains no comprehensive synthesis evaluating the impact of xerostomia across dental treatment modalities. This knowledge gap limits clinical awareness and evidence-based decision-making for affected patients. A systematic review is therefore warranted to consolidate current evidence, highlight gaps, and guide strategies to optimize dental treatment outcomes in patients with xerostomia. Methods The following systematic review was conducted in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) [ 11 ] and is registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD420251035790. Focused question The question was defined in accordance with the Population, Intervention, Comparison, Outcome method (PICO) [ 12 ]. What are the clinical outcomes of dental treatment carried out in patients with xerostomia ? Primary Outcome Dental restoration failure, prosthetic instability, implant failure, periodontal treatment outcomes, caries recurrence, wound healing Secondary outcome Patient-reported outcomes (pain, discomfort, quality of life), treatment modifications or retreatments. Inclusion criteria Publications were eligible for inclusion if they involved human subjects with xerostomia or hyposalivation of any etiology, including Sjögren’s syndrome, medication-induced xerostomia, radiation-induced xerostomia, or systemic disease–related salivary dysfunction. Studies were required to report at least one dental treatment outcome, such as restoration longevity, implant survival, periodontal healing, prosthesis retention, or patient-reported oral health–related quality of life. Eligible designs included randomized controlled trials, cohort studies, case-control studies, and cross-sectional studies, provided that sufficient quantitative or qualitative outcome data were available. Only full-text articles published in English were considered. Exclusion Criteria Exclusion criteria were animal or in vitro studies, narrative reviews, systematic reviews, meta-analyses, conference abstracts without complete data, and case reports or case series with fewer than five patients. Studies focusing solely on xerostomia prevalence, pathophysiology, or pharmacologic management without reference to dental treatment outcomes were excluded. Likewise, publications unrelated to conventional dental implants or restorative/prosthetic therapy, as well as non-English language reports, were not considered. Search strategy Table 1 Search strategy according to the focused question (PICO) Focused Question (PICO) What are the clinical outcomes of dental treatment carried out in patient with xerostomia Search strategy Population Patients with xerostomia or hyposalivation of any etiology (e.g., Sjögren’s syndrome, medication-induced, radiation-induced, systemic disease) Intervention Dental treatments, including restorative procedures, implant placement, periodontal therapy, and prosthodontic rehabilitation Comparisons Patients without xerostomia, alternative dental materials or interventions, or within-patient comparisons (when applicable). Outcome Restoration longevity/failure, implant survival, periodontal healing, prosthesis retention/stability, and patient-reported oral health–related quality of life We conducted a comprehensive search of the literature in three electronic databases: PubMed, Embase, and Google Scholar, to identify relevant studies reporting clinical outcomes of dental treatments in adults (≥ 18 years) with xerostomia, including those with Sjögren’s syndrome or other etiologies of dry mouth. The search included both controlled vocabulary terms (MeSH and Emtree) and free-text keywords to capture a broad range of studies. PubMed The PubMed search strategy combined MeSH terms and text words related to xerostomia and Sjögren’s syndrome, dental procedures, and treatment outcomes. The full search strategy was: ("Xerostomia"[Mesh] OR "Sjögren's Syndrome"[tiab] OR "Sicca Syndrome"[tiab] OR xerostomia[tiab] OR "dry mouth"[tiab]) AND ("Dental Care"[Mesh] OR "Dental Implants"[Mesh] OR "Endodontics"[Mesh] OR "Tooth Extraction"[Mesh] OR "Prosthodontics"[Mesh] OR dental treatment*[tiab] OR dental procedure*[tiab] OR dental implant*[tiab] OR tooth extraction*[tiab] OR exodontia*[tiab] OR periodontal therap*[tiab] OR “restoration*[tiab]) AND ("Treatment Outcome"[Mesh] OR "Postoperative Complications"[Mesh] OR "Wound Healing"[Mesh] OR "Recurrence"[Mesh] OR "Dental Restoration Failure"[Mesh] OR treatment outcome*[tiab] OR complication*[tiab] OR dental implant failure[tiab] OR implant failure[tiab] OR recurrence[tiab] OR failure[tiab] OR healing[tiab]) Filters applied: Humans, English language, adults (≥ 18 years). Embase The Embase search used Emtree terms and text words: ('xerostomia'/exp OR 'xerostomia':ti,ab OR 'dry mouth':ti,ab OR 'sjogren syndrome':ti,ab OR 'sicca syndrome':ti,ab) AND ('dental care'/exp OR 'dental implant'/exp OR 'endodontics'/exp OR 'tooth extraction'/exp OR 'prosthodontics'/exp OR 'dental treatment*':ti,ab OR 'dental procedure*':ti,ab OR 'dental implant*':ti,ab OR 'tooth extraction*':ti,ab OR 'exodontia*':ti,ab OR 'periodontal therap*':ti,ab) AND ('treatment outcome'/exp OR 'postoperative complication'/exp OR 'wound healing'/exp OR 'recurrence'/exp OR 'dental restoration failure'/exp OR 'treatment outcome*':ti,ab OR 'complication*':ti,ab OR 'implant failure':ti,ab OR 'dental implant failure':ti,ab OR 'recurrence':ti,ab OR 'healing':ti,ab OR 'failure':ti,ab) Filters applied: Humans, English language, adults (≥ 18 years). Google Scholar A simplified search was performed on Google Scholar using the terms: ("xerostomia" OR "dry mouth" OR "sjogren's syndrome") AND ("dental treatment" OR "dental procedure" OR "implant" OR "restoration" OR "tooth extraction") AND ("treatment outcome" OR "complication" OR "healing" OR "recurrence" OR “failure”) The first 200 results were screened manually in incognito mode to reduce personalization bias. Reference lists of included studies were also screened to identify any additional relevant studies. Study Selection Two independent reviewers (S.P, P.K) screened titles and abstracts of retrieved studies for eligibility. Full-text articles of potentially relevant studies was assessed for inclusion. Discrepancies between reviewers was resolved through discussion or consultation with a third reviewer (P.P). The selection process was documented using a PRISMA flow diagram. Data Extraction Data from included studies was extracted independently by two reviewers (S.P, P.K) using a standardized data extraction form. Extracted data included: Study characteristics (author, year, country, study design), participant characteristics (age, gender, xerostomia diagnosis method), details of dental treatment(s) performed, outcomes measured and results, funding sources and conflicts of interest. Any disagreements was resolved through discussion or consultation with a third reviewer (P.P). Authors of included studies were contacted for missing or unclear data. Ethical considerations No personal information of patients was used in this systematic review. All data was extracted from publicly available scientific publications. No informed consent or ethical approval was required for this systematic review. Risk of bias assessment The risk of bias in included studies was assessed independently by two reviewers (S.P, P.K): Randomized Controlled Trials: Cochrane Risk of Bias Tool (RoB 2) [ 13 ] Non-Randomized Studies: ROBINS-I (Risk Of Bias In Non-randomized Studies – of Interventions) tool [ 14 ] Discrepancies was resolved through discussion or consultation with a third reviewer (P.P). Certainty of Evidence The certainty of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach [ 15 ]. Each outcome was rated as high, moderate, low, or very low certainty. Two reviewers (S.P, P.K) independently conducted the GRADE assessments, with discrepancies resolved through discussion or consultation with a third reviewer (P.P). Results Literature search A comprehensive literature search identified 244 records through electronic databases. After removing 27 duplicates, 217 unique records remained. Following title and abstract screening, 175 articles were excluded for irrelevance. Full-text screening was conducted for 15 articles, of which 18 studies were ultimately included in the review (12 from the database search and an additional 6 identified through reference screening). During the full-text assessment, 8 publications were excluded because they were case reports or case series with fewer than five cases, which did not meet the predefined inclusion criteria. Other reasons for exclusion included insufficient outcome reporting and studies unrelated to dental treatment outcomes in xerostomia. Study characteristics The characteristics of the included studies are presented in Table 2 . One randomized controlled trial, one non-randomized interventional trial, five prospective cohort studies, seven retrospective cohort studies and two cross-sectional studies were included in the present systematic review. Table 2 Results of literature search Study (Year) Design (N) Xerostomia cause Intervention (Comparator) Key findings Bidyasgagar et al., 2023 [ 26 ] Retrospective cohort (N = 100; 50 xerostomia, 50 control) Not specified (medically compromised vs healthy) Dental implants (vs healthy controls) Higher implant failure in xerostomia group (10% vs 0%) and more tooth loss. Kaur et al., 2018 [ 27 ] Non-randomized interventional (N = 60; 24 pSS, 36 controls) Primary Sjögren’s syndrome (pSS) Periodontal therapy (SRP) (vs nose-breathing controls) pSS group had significantly lower plaque and gingival indices at 12 weeks (p < 0.01). Albrecht et al., 2016 [ 24 ] Cohort (N = 292; 205 Sjögren’s [76% pSS], 87 controls) Sjögren’s syndrome (mixed pSS/sSS) Dental implants (vs healthy controls) Implant survival ~ 100% in both groups; no difference in bone loss or failure rates. Isidor et al., 1999 [ 29 ] Prospective (N = 8; all pSS) Primary Sjögren’s syndrome (pSS) Single implant-supported crowns (no control) 13% implant failure; all remaining implants functioned at ~ 3 years, high patient satisfaction. Hosseini et al., 2025 [ 21 ] Prospective (N = 47; 23 pSS, 24 controls) Primary Sjögren’s syndrome (pSS) Implant-supported overdentures (vs controls) 100% implant survival in both groups; no significant differences in bone loss or probing depths. Ettl et al., 2016 [ 23 ] Prospective (N = 29 patients; 165 implants) Medication/radiation-induced xerostomia Dental implants (no control group) 95% implant survival at 1 year, 94% at 5 years; xerostomia not a significant factor for success. Petrovic et al., 2019 [ 30 ] Mixed retrospective/prospective (N = 25) Primary Sjögren’s syndrome (pSS) Fibula graft oral rehabilitation (implants) (no control) Mean oral function ~ 64% of normal; recovery similar with or without pSS. Leinonen et al., 2021 [ 6 ] Retrospective cohort (N = 213; 71 pSS, 142 controls) Primary Sjögren’s syndrome (pSS) Dental restorations (various) (vs non-SS controls) Xerostomia patients had higher restoration failure (hazard ratio ≈ 2.6 vs controls, p < 0.001). DeMoor et al., 2011 [ 18 ] Prospective controlled trial (N = 35) Radiation-induced xerostomia Class V restorations (GIC vs RMGIC vs composite) Glass ionomer restorations had significantly fewer recurrent caries than composite/RMGIC (p < 0.05). McComb et al., 2002 [ 17 ] Randomized trial (N = 45) Radiation-induced xerostomia Class V restorations (GIC vs RMGIC vs composite; within-patient comparison) No overall significant differences; composite failed more often in non-fluoride users. Sparrow et al., 2021 [ 28 ] Retrospective (N = 119; 34 pSS/sSS, 85 controls) Sjögren’s syndrome (pSS/sSS) Periodontal maintenance (SRP) (vs non-xerostomia controls) No significant differences in probing depth reduction or other indices between groups. Maarse et al., 2022 [ 20 ] Prospective cohort (N = 34; 17 pSS/sSS, 17 controls) Sjögren’s syndrome (pSS/sSS) Dental implants (vs age/sex-matched controls) Implant survival 100% (SS) vs 96% (controls, p = 0.06); SS patients had more peri-implant mucositis. Siddiqui et al., 2017 [ 25 ] Retrospective EDR (N = 180 SS patients) Xerostomia (likely Sjögren’s) Various dental treatments (vs healthy controls) Xerostomia patients had more dental treatments; implant survival 87.6% vs 95.7% in controls (p < 0.001). Gomez et al., 2024 [ 16 ] Retrospective EDR/EHR (N = 144; 102 pSS, 42 controls) Primary Sjögren’s syndrome (pSS) Multi-surface restorations (vs controls) Higher restoration failure in pSS (HR ≈ 2.9, 95% CI 2.3–3.7); failures occurred ~ 1 year sooner than controls. Korfage et al., 2015 [ 22 ] Retrospective cohort (N = 100; 50 pSS, 50 controls) Primary Sjögren’s syndrome (pSS) Dental implants (vs controls) Implant survival 97% (pSS) vs 100% (controls, ns); SS had worse peri-implant plaque but similar clinical outcomes. Haveman et al., 2003 [ 19 ] Comparative interventional (N = 36) Radiation-induced xerostomia Class I/II restorations (amalgam vs RMGIC; fluoride vs non-user) Fluoride users had no recurrent caries; among non-users, composite had more failures than GIC (p < 0.05). Sample sizes ranged widely, from fewer than 10 participants (8) in early implant rehabilitation case series to 290 patients. The study populations represented multiple xerostomia etiologies, including primary and secondary Sjögren’s syndrome, post–head and neck radiotherapy, medication-induced hyposalivation, and mouth breathing. Participants were typically middle-aged or older adults (mean ages 50–70 years), with women comprising the majority in Sjögren’s cohorts, while sex distribution was more balanced in general restorative or periodontal studies. The dental interventions evaluated fell into four broad categories: dental implants (survival of crowns, overdentures, full-arch prostheses), restorative treatments (composite/GIC fillings, crowns), periodontal therapy (scaling/root planing) and reconstructive surgery (mandibulectomy followed by reconstruction). Implant studies often used matched healthy controls (e.g. pSS vs control), whereas restorative trials compared materials within xerostomic patients (often stratified by fluoride use). Follow-up durations varied widely, ranging from several weeks (periodontal healing studies) to 2–5 years (implant and restorative studies). Due to substantial heterogeneity in study design, outcome measures, and xerostomia etiologies, a formal meta-analysis could not be performed. Literature analysis Restoration survival/failure Five studies evaluated restoration outcomes in xerostomia. Large cohort studies (Leinonen 2021; Gomez 2024) [ 6 , 16 ] consistently demonstrated higher failure rates among xerostomic patients compared with controls (HR ~ 2–3). Material-specific trials in radiation-induced xerostomia favored fluoride-releasing glass ionomer cements (GIC) over composite or amalgam. McComb (2002) [ 17 ] and De Moor (2011) [ 18 ] both found that GIC significantly reduced recurrent caries compared with resin composites, although GIC showed greater marginal erosion. Haveman (2003) [ 19 ] similarly reported no recurrent caries in fluoride users regardless of material, but in fluoride non-users eight amalgam restorations and one RMGI failed from recurrent caries, while some conventional GIC failed due to material loss. Overall, xerostomia increased restoration failure risk, and fluoride-releasing materials performed better than composites or amalgam. The certainty of evidence was low. Implant survival/success Eight cohort studies (≈ 300 implants) assessed implant survival in xerostomic patients. Across Sjögren’s cohorts (Maarse 2022; Hosseini 2025; Korfage 2015) [ 20 – 22 ], survival ranged from 97% to 100% at 18 months to 5 years, comparable to controls. Quality-of-life consistently improved following implant rehabilitation. In contrast, radiation-induced xerostomia was associated with earlier failures. Ettl (2016) [ 23 ] reported implant losses within the first year post-radiotherapy, and Albrecht (2016)(24) observed higher failure prevalence in Sjögren’s (4.8%) versus controls (0%). Siddiqui (2017) [ 25 ] reported 87% survival at ~ 40 months, and Bidyasagar (2023) [ 26 ] described failures in medically compromised groups that included xerostomia. Overall implant survival averaged ~ 94%, with moderate certainty evidence, though radiation-induced xerostomia appeared to carry higher risk. Periodontal outcomes Two studies assessed periodontal treatment response in xerostomia proxies. Kaur (2018) [ 27 ] found that mouth-breathing patients had slower early improvement in gingival and bleeding indices after scaling and root planing, though outcomes equalized by 12 weeks. Sparrow (2021) [ 28 ] reported similar probing depths and plaque scores between xerostomic and non-xerostomic patients during long-term maintenance. Evidence suggested xerostomia may delay short-term healing but not long-term outcomes. Certainty was low. Patient-reported outcomes Six studies investigated patient-centered measures. Isidor (1999) [ 29 ] demonstrated improved prosthesis comfort, chewing ability, and self-confidence with implant-retained dentures in Sjögren’s patients. Hosseini (2025) [ 21 ] and Maarse (2022) [ 20 ] showed that OHRQoL improved significantly in both xerostomia and control groups, though scores remained lower in Sjögren’s across follow-up. Tobias ] and Korfage [ 22 ] similarly reported significant functional gains, including chewing, swallowing, and social eating. Petrovic (2019) [ 30 ] reported overall worse asthetic outcomes in patients with post-radiotherapy xerostomia who under rehabilitation after mandibulectomy. Overall, xerostomic patients reported meaningful improvement after dental rehabilitation, though baseline and post-treatment QoL remained lower than in controls. Certainty was low. Prosthesis retention One small study (Isidor 1999; n = 8 Sjögren’s patients) [ 29 ] directly assessed prosthesis retention. No implant-retained dentures were lost or remade over two years despite severe dryness. Evidence for this outcome remains very limited (very low certainty). Risk of bias assessment Overall, the risk of bias was high to serious for most included studies, as shown in Table 3 . The single randomized controlled trial (McComb 2002) had high risk due to inadequate reporting of randomization, lack of blinding, and incomplete outcome data. All non-randomized studies were assessed using the ROBINS-I tool, with most rated as “serious” risk of bias primarily from confounding (e.g., differences in systemic conditions, medication use, or radiation exposure) and selection bias, while outcome measurement was generally objective and consistently reported. A few prospective cohorts (e.g., Maarse 2022, Hosseini 2025) had moderate risk, supported by clearer protocols and more complete follow-up, but residual confounding remained a concern. Table 3 Risk of Bias (RoB 2.0) for Randomized Controlled Trial(s) Study (Author–Year) Randomization process Deviations from intervention Missing outcome data Outcome measurement Selective reporting Overall RoB Rationale (short) McComb 2002 [ 17 ] High risk — insufficient reporting of random sequence generation and allocation concealment (abstract/limited methods). Low / Some concerns — interventions delivered as intended within patients (split-mouth), but no blinding described. Some concerns — attrition reported (losses to follow-up), numbers not fully detailed in abstract. Some concerns — outcomes (secondary caries, marginal integrity) are objective but assessments likely unblinded. Some concerns — limited reporting detail in available record (full methods/results not fully described). High Randomization and allocation concealment not clearly described; small sample and incomplete reporting increase risk of bias and limit confidence. Certainty of evidence assessment The certainty of evidence, graded using the GRADE approach as shown in Table 4 , was low to very low for most outcomes, reflecting the predominance of small, non-randomized studies with methodological limitations. Evidence on implant survival in xerostomic patients was judged moderate certainty, as results were consistent across several cohorts with survival rates > 90% despite different xerostomia etiologies, though confounding and limited long-term follow-up reduced confidence. In contrast, evidence on restoration survival and periodontal treatment outcomes was of low to very low certainty, due to high risk of bias, small sample sizes, and heterogeneity in interventions and outcome definitions. No direct data were available on denture/prosthesis retention, leaving certainty as “very low.” Table 4 Risk of Bias (ROBINS-I) for non-randomized studies Study (Author–Year) Confounding Selection of participants Intervention classification Deviations from intended interventions Missing data Outcome measurement Selective reporting Overall ROBINS-I Rationale (short) Bidyasagar 2023 [ 26 ] Serious — groups (compromised vs healthy) inherently confounded by comorbidities (e.g., diabetes). Moderate — retrospective chart sampling; inclusion criteria not fully defined. Low — implant exposure clearly recorded. Low — same implant procedures across groups. Low — 1-yr follow-up reported for all implants. Low — implant failure objectively defined (loss/MBL). Low — main outcomes reported. Serious Retrospective non-random grouping by health status with no adjustment for key confounders; objective outcomes but limited adjustment. Kaur 2018 [ 27 ] Serious — mouth-breathing (proxy for xerostomia) can be associated with other baseline differences. Moderate — selection unclear (convenience sample). Low — SRP applied consistently. Low — no differential deviations reported. Some concerns — small sample and some dropouts. Moderate — clinical indices (BOP, PI) measured, but likely unblinded. Low — reported as planned. Serious Non-random allocation by habit (mouth-breathers vs controls) and small sample increase risk of confounding and measurement bias. Albrecht 2016 [ 24 ] Serious — baseline differences (age, oral health, meds) between SS and controls likely. Moderate — cohort sampling likely adequate but non-contemporaneous controls used. Low — implant exposure well defined. Low — routine care. Low — follow-up reported. Moderate — some outcomes self-reported; clinical indices varied. Low — outcomes reported. Serious Large cohort but residual confounding from disease and medication; some patient-reported measures introduce measurement variability. Isidor 1999 [ 29 ] Serious — single-arm SS cohort; no concurrent controls. Moderate — consecutive implant patients but small and selected. Low — intervention clearly recorded. Low — same protocol applied. Low — short follow-up with few losses. Moderate — objective survival, but examiners unblinded and small N. Low Serious Single-arm prospective series without control group; high risk of confounding by indication and limited generalizability. Hosseini 2025 [ 21 ] Moderate — matching reduces confounding but residual differences remain (comorbidities). Low — matched consecutive recruitment. Low — exposure clearly classified. Low — standardized interventions. Moderate — small attrition by 5 years but reported. Moderate — clinical indices by single examiner (not blinded). Low — outcomes fully reported. Moderate Well-conducted matched cohort but limited sample size and potential residual confounding; objective implant outcomes. Ettl 2016 [ 23 ] Serious — radiotherapy and cancer status confound outcomes; limited adjustment. Low — prospective cohort with clear inclusion. Low — exposure (RT/no RT) recorded. Low — standard care. Low — 1-yr follow-up complete. Low–Moderate — implant survival objective; QoL subjective but validated. Low Moderate Prospective design but major confounding by RT and cancer characteristics; outcomes largely objective but limited control of confounders. Petrović 2019 [ 30 ] Serious — heterogenous survivors (RT, trismus) introduce confounding. Serious — survivor recall and selection bias (25 subjects). Low — intervention (fibula + rehabilitation) clearly identified. Low — observational follow-up only. Moderate — potential non-attendance and survival bias. Moderate — outcomes (QoL, esthetics) subjective; multiple raters. Low Serious Small, selected survivor cohort with likely survivorship/selection biases and subjective outcomes. Leinonen 2021 [ 6 ] Serious — residual confounding possible despite large registry; etiologies heterogeneous. Low–Moderate— registry sampling good but cause classification may be imperfect. Low — restoration classification clear. Low — no intended deviations. Low — registry completeness good; attrition minimal. Low — objective restoration survival from records. Low Moderate–Serious Large registry provides strong objective outcome data, but residual confounding and heterogeneity of xerostomia causes justify concern. DeMoor 2011 [ 18 ] Moderate — within-patient comparisons reduce confounding; allocation method unclear. Low — patients required ≥ 3 restorations, selected. Low — materials clearly assigned per site. Low — interventions per protocol. Moderate — some attrition by 24 months. Moderate — restoration outcomes clinically assessed, examiners likely unblinded. Low Moderate Prospective clinical design with split-mouth elements, but unclear random sequence and some attrition weaken internal validity. Sparrow 2021 [ 28 ] Serious — mixed xerostomia etiologies and potential confounders (meds, baseline severity). Moderate — convenience sample of maintenance patients. Low — xerostomia classification via unstimulated flow was performed. Low — maintenance delivered as routine. Low — cross-sectional maintenance visit data complete. Moderate — PD/PI measured but examiners not blinded. Low Moderate–Serious Retrospective maintenance assessment with objective outcomes but potential confounding by xerostomia etiology and unmeasured factors. Maarse 2022 [ 20 ] Moderate — group differences possible; mixed adjustments with mixed models. Low — multicenter prospective inclusion with clear criteria. Low — implant exposure clearly recorded. Low — standardized surgical/restorative protocol across centers. Low — 18-month follow-up largely complete. Low — implant survival and MBL objectively measured. Low Moderate Prospective multicenter design strengthens evidence but sample modest and residual confounding possible; objective outcomes. Siddiqui 2017 [ 25 ] Serious — limited adjustment for disease severity, meds, or oral hygiene. Moderate–Serious — single-center EDR convenience sample; selection criteria incompletely described. Low — interventions accurately captured in EDR. Low — routine care delivered. Some concerns — missing baseline data and variable record completeness. Low–Moderate — EDR outcome definitions pragmatic but may vary. Low Serious Large retrospective EDR study with objective outcomes, but substantial residual confounding and variable data completeness. Gomez 2024 [ 16 ] Serious — residual confounding by meds, baseline caries risk, and behavior despite adjustment. Moderate — matched controls but retrospective selection may bias. Low — restorations and exposures well classified. Low — standard clinical care documented. Low — survival/failure data available for most restorations. Low — restoration failure operationalized objectively. Low Serious Robust EDR/EHR analysis but still susceptible to unmeasured confounders and imprecision in some subgroups. Korfage 2015 [ 22 ] Serious — SS patients differ in meds, disease activity vs historic controls. Serious — 19/69 eligible SS with implants did not undergo exam; controls historic. Low — exposure recorded (implants) Low — standard care across centers. Moderate — baseline radiographs missing for ~ 48% (MBL analysis affected). Moderate — clinical indices measured by different examiners across groups. Low Serious Selection bias (non-participation), historic control matching, and missing baseline radiographs are major concerns for bone loss and peri-implant comparisons. Haveman 2003 [ 19 ] Serious — very small N (9 patients) and fluoride compliance strongly confounds results. Serious — convenience sample with possible selection of severe cases. Low — materials and grouping (fluoride users vs non-users) clearly described. Low — restorative procedures as intended. Moderate — 86% of restorations evaluated at 2 years (some loss to follow-up). Moderate — caries assessment clinical and photographic, but assessor not blinded; outcome clustering by patient. Low Serious Small sample, strong confounding by fluoride compliance and patient-level clustering; limits generalizability despite objective outcomes. Table 5 Certainty assessment of the study outcomes Outcome Studies (total N) Certainty (GRADE) Comments (downgrading factors) Implant survival/success 8 studies (observational data) Moderate Evidence from non-randomized studies; downgraded for risk of bias and imprecision, but results were generally consistent with good implant survival. Restoration survival/failure 5 studies (observational) Low Observational evidence; heterogeneity in materials and patient causes; wide confidence intervals. Downgraded for bias, inconsistency, imprecision. Periodontal outcomes (e.g. PD) 2 studies (observational) Low Few small studies; evidence limited to adult xerostomia (mainly Sjögren’s). Downgraded for risk of bias and imprecision. Patient-reported outcomes (QoL, comfort) 2 studies (observational) Moderate Consistent improvements reported after treatment, but only small cohort data. Downgraded for bias (non-randomized) and imprecision. Discussion Restoration outcomes Patients with xerostomia, or dry mouth, are at increased risk for dental caries because of the loss of saliva and its protective functions [ 31 ]. A reduction in salivary flow increases oral acidity and promotes proliferation of acidogenic bacteria, while impairing buffering capacity, mineral replenishment, and lubrication of tooth surfaces [ 31 ]. Together, these factors accelerate caries development and compromise restoration longevity [ 31 ]. Consistent with this biological plausibility, retrospective cohort studies show that xerostomic patients often lose restorations earlier than non-xerostomic controls. Gomez et al. (2024) [ 16 ] reported that patients with Sjögren’s syndrome had nearly three-fold higher risk of restoration failure (hazard ratio ~ 3.0) compared to matched controls, with five-year survival rates of ~ 55% versus ~ 75%. Leinonen et al. (2021) [ 6 ] similarly observed shorter survival of restorations in Sjögren’s and radiotherapy-induced xerostomia compared with patients who had hyposalivation of unspecified origin. The authors suggested that poorer saliva quality, trismus, and mucosal sensitivity in these groups may hinder oral hygiene and further reduce restoration longevity [ 6 ]. Failures were most often due to recurrent caries at restoration margins, a finding supported by other caries risk studies in xerostomia [ 32 ]. Several small clinical trials have evaluated material choice. Haveman et al. (2003) [ 19 ] found that glass ionomer–based materials reduced recurrent caries compared with amalgam in fluoride non-users, although conventional GIC showed some erosion-related failures. Importantly, the study was limited by very small sample size and confounding by fluoride compliance. The authors nevertheless highlighted the potential advantage of fluoride-releasing materials in radiation-induced xerostomia, though larger controlled trials are needed. An earlier trial by Wood et al. (1993) [ 33 ] placed paired restorations in 36 xerostomic head and neck cancer patients. Results showed a striking interaction with fluoride use: in fluoride users, glass ionomer cement failed while amalgam survived, whereas in non-users, the opposite occurred (glass ionomer survived, amalgam failed). Mean time to failure was 8.5 months, with more pronounced effects in severely xerostomic patients. Taken together, these studies suggest that xerostomia substantially increases restoration failure risk, largely through recurrent caries. Material selection appears important: fluoride-releasing cements may be advantageous in patients with poor fluoride compliance, while amalgam performs better when topical fluoride is used regularly. However, evidence is limited, heterogeneous, and of low certainty, underscoring the need for well-designed trials to guide restorative choices in xerostomic patients. Implant survival/success Most included studies demonstrated that implant therapy in patients with Sjögren’s syndrome yields survival rates comparable to non-xerostomic controls, typically above 94% over 3–5 years. Quality-of-life improvements were consistent, with patients reporting better function, comfort, and oral health-related quality of life (OHRQoL) after rehabilitation [ 34 ]. These results align with systematic reviews in healthy populations, which report 10-year implant survival rates of 95–97% [ 34 – 37 ]. However, outcomes were notably poorer in radiation-induced xerostomia. Failures occurred within the first year after therapy, contrasting with the more gradual failures in Sjögren’s syndrome. Radiation likely damages endothelial cells and microvasculature, producing chronic ischemia and impaired osseointegration. These mechanisms may explain why radiation-induced xerostomia carries a higher implant failure risk [ 38 ]. Overall, implants remain a viable option in xerostomia, especially for autoimmune etiologies, but patient selection and management of systemic factors are crucial. Periodontal outcomes Xerostomia reduces salivary clearance and increases plaque accumulation, leading to greater gingival inflammation and higher periodontitis risk [ 39 ]. Consistent with this, Kaur et al. (2018) [ 27 ] found that mouth-breathing patients had delayed early improvement in gingival indices following scaling and root planing compared with nasal breathers. By contrast, Sparrow et al. (2021) [ 28 ] observed that xerostomic patients maintained similar probing depths and plaque control to non-xerostomic controls over long-term maintenance, provided recall visits and hygiene support were frequent. These findings suggest xerostomia may delay short-term healing but, with diligent maintenance, periodontal outcomes can eventually approximate those of controls. Evidence remains very limited, and certainty is low. Patient outcomes Patient-centered outcomes consistently showed improvement after treatment. Studies of implant-supported prostheses in Sjögren’s patients reported significant improvements in chewing ability, swallowing, denture comfort, and overall OHRQoL (e.g., Maarse 2022; Hosseini 2025). However, baseline and post-treatment QoL remained worse in xerostomia patients compared with controls. Direct evidence for prosthesis retention was scarce; only one small study (Isidor 1999) showed stable implant-retained dentures over two years in xerostomic patients. Limitations This review is limited by the generally low quality of evidence. Most included studies were retrospective or small prospective cohorts, with non-random group allocation, unblinded outcome assessment, and limited control for confounders. Sample sizes were often small, follow-up periods varied, and outcomes were heterogeneous across xerostomia etiologies, treatments, and measures. These issues contributed to wide confidence intervals and predominantly low-to-moderate certainty ratings using GRADE. Clinical implications Xerostomia poses significant challenges for dental care, increasing caries risk and reducing restoration longevity. Preventive measures such as high-fluoride regimens, sealants, and frequent recall are essential. Resin-modified glass ionomers or moisture-tolerant materials may be preferred for restorations. Implant therapy generally shows good survival even in xerostomic patients, though careful case selection and systemic risk management are critical. Periodontal therapy can be effective with close maintenance, though early healing may be slower. Future research Robust prospective studies are needed, stratifying patients by xerostomia severity and cause, and employing standardized outcome measures and blinded assessment. Larger sample sizes and better control of confounders will allow stronger conclusions and meta-analysis. In particular, the lack of evidence on denture retention in xerostomia represents an important research gap. Future trials should also evaluate whether therapies for salivary stimulation or substitution can improve dental treatment outcomes. Conclusion Xerostomia appears to worsen the durability of dental restorations and may modestly challenge periodontal therapy, while implant-based prosthetic treatments remain generally successful. All rehabilitative treatments yielded patient-reported benefits. However, these conclusions rest on limited evidence with significant bias and imprecision. Clinicians should anticipate higher preventive and maintenance needs in xerostomia patients, and researchers should pursue robust trials to confirm and refine these findings. Abbreviations PRISMA P–Preferred Reporting Items for Systematic Review and Meta–Analysis Protocols PROSPERO International Prospective Register of Systematic Reviews PICO Population, Intervention, Comparison, Outcome RCT Randomized Controlled Trial RoB 2 Cochrane Risk of Bias Tool, version 2 ROBINS I–Risk of Bias in Non–randomized Studies–of Interventions GRADE Grading of Recommendations, Assessment, Development, and Evaluation QoL Quality of Life OHRQoL Oral Health–Related Quality of Life GIC Glass Ionomer Cement RMGI Resin–Modified Glass Ionomer Declarations Availability of data and materials All data are included into the manuscript. Acknowledgement Not applicable. Funding Not applicable. Competing interests The authors declare no competing interests. Author information Prakash Kafle and Prativa Pandey had equal contribution in the work and share the second authorship. Contributions Conceptualization, S.P.; methodology, S.P., P.K., and P.P.; software, P.K. and P.T.; validation, S.P. and S.G.; formal analysis, S.P., P.P., and A.B.; investigation, S.P. and A.B.; resources, P.T. and S.G.; data curation, S.P., P.K., and P.P.; writing—original draft preparation, S.P.; writing—review and editing, P.K., P.P., A.B., P.T., and S.G.; visualization, P.K. and P.P.; supervision, B.S.; project administration, S.P. and B.S. All authors have read and agreed to the published version of the manuscript. Ethics declaration Ethical approval and consent to participate Ethical approval was not required for this study. Consent for publication Not applicable. References Kapourani A, Kontogiannopoulos KN, Manioudaki AE, Poulopoulos AK, Tsalikis L, Assimopoulou AN et al. A Review on Xerostomia and Its Various Management Strategies: The Role of Advanced Polymeric Materials in the Treatment Approaches. Polymers (Basel) [Internet]. 2022 Feb 22 [cited 2025 Sept 14];14(5):850. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8912296/ Talha B, Swarnkar SA. Xerostomia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 Sept 14]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK545287/ Guggenheimer J, Moore PA. Xerostomia: etiology, recognition and treatment. J Am Dent Assoc. 2003;134(1):61–9. quiz 118–9. Johansson AK, Johansson A, Unell L, Ekbäck G, Ordell S, Carlsson GE. Self-reported dry mouth in 50- to 80-year-old Swedes: Longitudinal and cross-sectional population studies. J Oral Rehabil. 2020;47(2):246–54. Uchida H, Ovitt CE. Novel impacts of saliva with regard to oral health. J Prosthet Dent [Internet]. 2022 Mar [cited 2025 Sept 14];127(3):383–91. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8669010/ Leinonen J, Vähänikkilä H, Raninen E, Järvelin L, Näpänkangas R, Anttonen V. The survival time of restorations is shortened in patients with dry mouth. J Dent. 2021;113:103794. Brand HS, Ligtenberg AJM, Veerman ECI. Saliva and wound healing. Monogr Oral Sci. 2014;24:52–60. Cahyani SP, Maharani AT. Alfisa’ida ‘Aliyya, Tantiana. The effect of Xerostomia in diabetes mellitus patients on the incidence of dry socket after tooth extraction: A literature review. World Journal of Advanced Research and Reviews [Internet]. 2024 [cited 2025 Sept 14];24(1):1650–5. Available from: https://wjarr.com/content/effect-xerostomia-diabetes-mellitus-patients-incidence-dry-socket-after-tooth-extraction Hori Y, Kondo Y, Nodai T, Masaki C, Ono K, Hosokawa R. Xerostomia aggravates ligation-induced peri-implantitis: A preclinical in vivo study. Clinical Oral Implants Research [Internet]. 2021 [cited 2025 Sept 14];32(5):581–9. Available from: https://onlinelibrary.wiley.com/doi/abs/ 10.1111/clr.13727 Diz P, Scully C, Sanz M. Dental implants in the medically compromised patient. Journal of Dentistry [Internet]. 2013 Mar 1 [cited 2025 Sept 14];41(3):195–206. Available from: https://www.sciencedirect.com/science/article/pii/S0300571213000043 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. Eriksen MB, Frandsen TF. The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search quality: a systematic review. J Med Libr Assoc. 2018;106(4):420–31. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ [Internet]. 2011 Oct 18 [cited 2025 Sept 14];343:d5928. Available from: https://www.bmj.com/content/343/bmj.d5928 Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ [Internet]. 2016 Oct 12 [cited 2025 Sept 14];355:i4919. Available from: https://www.bmj.com/content/355/bmj.i4919 Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ [Internet]. 2008 Apr 24 [cited 2025 Sept 14];336(7650):924–6. Available from: https://www.bmj.com/content/336/7650/924 Gomez GGF, Wang M, Siddiqui ZA, Gonzalez T, Capin OR, Willis L, et al. Longevity of dental restorations in Sjogren’s disease patients using electronic dental and health record data. BMC Oral Health. 2024;24(1):203. McComb D, Erickson RL, Maxymiw WG, Wood RE. A clinical comparison of glass ionomer, resin-modified glass ionomer and resin composite restorations in the treatment of cervical caries in xerostomic head and neck radiation patients. Oper Dent. 2002;27(5):430–7. De Moor RJG, Stassen IG, van ’t Veldt Y, Torbeyns D, Hommez GMG. Two-year clinical performance of glass ionomer and resin composite restorations in xerostomic head- and neck-irradiated cancer patients. Clin Oral Investig. 2011;15(1):31–8. Haveman CW, Summitt JB, Burgess JO, Carlson K. Three restorative materials and topical fluoride gel used in xerostomic patients: a clinical comparison. J Am Dent Assoc. 2003;134(2):177–84. Maarse F, Fennis WMM, Twisk JWR, Korfage A, Santing HJ, den Hartog L, et al. Dental implants in dentate primary and secondary Sjögren’s syndrome patients: A multicenter prospective cohort study. Clin Oral Implants Res. 2022;33(11):1157–70. Hosseini M, Jensen SS, Gotfredsen K, Hyldahl E, Pedersen AML. Prognosis of Single Implant-Supported Prosthesis in Patients With Primary Sjögren’s Syndrome: A Five-Year Prospective Clinical Study. Clin Oral Implants Res. 2025;36(1):51–63. Korfage A, Raghoebar GM, Arends S, Meiners PM, Visser A, Kroese FG, et al. Dental Implants in Patients with Sjögren’s Syndrome. Clin Implant Dent Relat Res. 2016;18(5):937–45. Ettl T, Weindler J, Gosau M, Müller S, Hautmann M, Zeman F et al. Impact of radiotherapy on implant-based prosthetic rehabilitation in patients with head and neck cancer: A prospective observational study on implant survival and quality of life—Preliminary results. Journal of Cranio-Maxillofacial Surgery [Internet]. 2016 Sept 1 [cited 2025 Sept 14];44(9):1453–62. Available from: https://www.sciencedirect.com/science/article/pii/S1010518216301500 Albrecht K, Callhoff J, Westhoff G, Dietrich T, Dörner T, Zink A. The Prevalence of Dental Implants and Related Factors in Patients with Sjögren Syndrome: Results from a Cohort Study. J Rheumatol. 2016 July;43(7):1380–5. Siddiqui Z, Wang Y, Makkad P, Thyvalikakath T. Characterizing Restorative Dental Treatments of Sjögren’s Syndrome Patients Using Electronic Dental Records Data. Stud Health Technol Inf. 2017;245:1166–9. Bidyasagar Bal SC, Awinashe VN, Jindal P, Khader AA, Almutairi FJ, Parihar AS, et al. Retrospective Analysis of Dental Implant Failure Rates in Patients with Compromised Health. J Pharm Bioallied Sci. 2023 July;15(Suppl 2):S1149–51. Kaur M, Sharma RK, Tewari S, Narula SC. Influence of mouth breathing on outcome of scaling and root planing in chronic periodontitis. BDJ Open. 2018;4:17039. Sparrow TV, Fritz PC, Sullivan PJ, Ward WE. Regular maintenance appointments after non-surgical scaling and root planing support periodontal health in patients with or without dry mouth: A retrospective study. Clin Exp Dent Res. 2021;7(5):647–55. Isidor F, Brøndum K, Hansen HJ, Jensen J, Sindet-Pedersen S. Outcome of treatment with implant-retained dental prostheses in patients with Sjögren syndrome. Int J Oral Maxillofac Implants. 1999;14(5):736–43. Petrovic I, Baser R, Blackwell T, McCarthy C, Ganly I, Patel S, et al. Long-term functional and esthetic outcomes after fibula free flap reconstruction of the mandible. Head Neck. 2019 July;41(7):2123–32. Su N, Marek CL, Ching V, Grushka M. Caries prevention for patients with dry mouth. J Can Dent Assoc. 2011;77:b85. Chisini LA, Collares K, Cademartori MG, de Oliveira LJC, Conde MCM, Demarco FF, et al. Restorations in primary teeth: a systematic review on survival and reasons for failures. Int J Paediatr Dent. 2018;28(2):123–39. Wood RE, Maxymiw WG, McComb D. A clinical comparison of glass ionomer (polyalkenoate) and silver amalgam restorations in the treatment of Class 5 caries in xerostomic head and neck cancer patients. Oper Dent. 1993;18(3):94–102. Almeida D, Vianna K, Arriaga P, Moraschini V. Dental implants in Sjögren’s syndrome patients: A systematic review. PLoS One [Internet]. 2017 Dec 14 [cited 2025 Sept 14];12(12):e0189507. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730117/ Moraschini V, Poubel LA da, Ferreira C, Barboza VF. E dos SP. Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review. Int J Oral Maxillofac Surg. 2015;44(3):377–88. Hjalmarsson L, Gheisarifar M, Jemt T. A systematic review of survival of single implants as presented in longitudinal studies with a follow-up of at least 10 years. Eur J Oral Implantol. 2016;9(Suppl 1):S155–162. Chrcanovic BR, Kisch J, Wennerberg A. Dental implants in patients with Sjögren’s syndrome: a case series and a systematic review. Int J Oral Maxillofac Surg. 2019 Sept;48(9):1250–9. Marx RE, Osteoradionecrosis. A new concept of its pathophysiology. Journal of Oral and Maxillofacial Surgery [Internet]. 1983 May 1 [cited 2025 Sept 14];41(5):283–8. Available from: https://www.joms.org/article/0278-2391(83)90294-X/fulltext Mizutani S, Ekuni D, Tomofuji T, Azuma T, Kataoka K, Yamane M, et al. Relationship between xerostomia and gingival condition in young adults. J Periodontal Res. 2015;50(1):74–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Feb, 2026 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 15 Dec, 2025 Reviews received at journal 30 Nov, 2025 Reviews received at journal 28 Nov, 2025 Reviewers agreed at journal 21 Nov, 2025 Reviewers agreed at journal 13 Nov, 2025 Reviewers invited by journal 06 Nov, 2025 Editor assigned by journal 30 Sep, 2025 Submission checks completed at journal 30 Sep, 2025 First submitted to journal 14 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7614524","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":515995259,"identity":"2ebbbbf7-dd55-46ed-bb3c-b9b66cdabd56","order_by":0,"name":"Sishir Poudel","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIie2PsUrEQBCGBwJJc7KdbLDYVxgRchb3MLMcWEkQ0lx1CBY2StocPoJNjkAqi4UUVsE2YhOb7YSUKd0Y77BIouWB+1U/7Hw78wNYLIeIAy5QHxFqAGJdpKu/KiaQf90pOLnH3YVeQdXnUcStp+v3JwgZX25rgnV49vIomxpBsGM1qGAxmyNpiPzkIkKCIgqqj4ybw043DzSsODOXkwKZVpcBJ1Ayr8q0UwjfhhVx4+mdMm/NYTJLyqydUqCAYL/F1Hdkyu7zyS2mS6fwyL/TkZksZFId5eeEfLSLiJ+136pFyLzltmlWaxnHZfbarhaCnYwc1sO/X3Gf+dT4Fz8+ZOrXaYvFYvlffAJK61+ScIc4jAAAAABJRU5ErkJggg==","orcid":"","institution":"B.P. Koirala Institute of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Sishir","middleName":"","lastName":"Poudel","suffix":""},{"id":515995260,"identity":"1a487537-2d48-473b-b76c-d433b7ba525b","order_by":1,"name":"Prakash Kafle","email":"","orcid":"","institution":"B.P. Koirala Institute of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Prakash","middleName":"","lastName":"Kafle","suffix":""},{"id":515995261,"identity":"e2dbcbb4-567d-4592-86e9-88c3219e99a4","order_by":2,"name":"Prativa Pandey","email":"","orcid":"","institution":"B.P. Koirala Institute of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Prativa","middleName":"","lastName":"Pandey","suffix":""},{"id":515995262,"identity":"08d1bf81-b632-4137-9781-e4c7ecaa3396","order_by":3,"name":"Pravin Thapa","email":"","orcid":"","institution":"B.P. Koirala Institute of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Pravin","middleName":"","lastName":"Thapa","suffix":""},{"id":515995263,"identity":"c5fa2049-86c0-48c2-ad2b-e59c32097626","order_by":4,"name":"Anup Baral","email":"","orcid":"","institution":"Gandaki Medical College","correspondingAuthor":false,"prefix":"","firstName":"Anup","middleName":"","lastName":"Baral","suffix":""},{"id":515995264,"identity":"99042732-ac59-42f7-9f87-fe9d0c2bbf33","order_by":5,"name":"Sangharsha Ghimire","email":"","orcid":"","institution":"B.P. Koirala Institute of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sangharsha","middleName":"","lastName":"Ghimire","suffix":""},{"id":515995266,"identity":"ea4ea257-03cb-43ec-897d-fab114e0004b","order_by":6,"name":"Bijay Subedi","email":"","orcid":"","institution":"Pokhara University","correspondingAuthor":false,"prefix":"","firstName":"Bijay","middleName":"","lastName":"Subedi","suffix":""}],"badges":[],"createdAt":"2025-09-14 20:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7614524/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7614524/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-026-07815-8","type":"published","date":"2026-02-02T15:57:35+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":92011109,"identity":"a096c3a9-290a-4f93-a732-1feea9d4e632","added_by":"auto","created_at":"2025-09-23 15:42:11","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":327226,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptFinal.docx","url":"https://assets-eu.researchsquare.com/files/rs-7614524/v1/24fd6c2f8175d1a30c3f7f15.docx"},{"id":92011107,"identity":"05cfa500-8375-48ef-83bd-099d159a49ed","added_by":"auto","created_at":"2025-09-23 15:42:11","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8308,"visible":true,"origin":"","legend":"","description":"","filename":"1f52462654af40e8907676998890f911.json","url":"https://assets-eu.researchsquare.com/files/rs-7614524/v1/02f0476f0d6e2a4f07e887cd.json"},{"id":92011893,"identity":"c0e9dff6-81ea-4a84-a623-218b03d56d5d","added_by":"auto","created_at":"2025-09-23 15:50:11","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":135520,"visible":true,"origin":"","legend":"","description":"","filename":"1f52462654af40e8907676998890f9111enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7614524/v1/667e9dc1b775c8437c4c3225.xml"},{"id":92011892,"identity":"f2572835-dc9e-4122-afaa-b88f33c13423","added_by":"auto","created_at":"2025-09-23 15:50:11","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":44397,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7614524/v1/b92beca9824a5d7144d719f2.png"},{"id":92011112,"identity":"879dfda2-c085-4384-8568-925ef1f71f51","added_by":"auto","created_at":"2025-09-23 15:42:11","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":133885,"visible":true,"origin":"","legend":"","description":"","filename":"1f52462654af40e8907676998890f9111structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7614524/v1/87316b4aeac4462289d2aa3b.xml"},{"id":92011110,"identity":"2b0fb4f2-7ae4-475a-b758-08cb1e9d58d6","added_by":"auto","created_at":"2025-09-23 15:42:11","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":144447,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7614524/v1/3211f6cf4c20006343f9b6dd.html"},{"id":92011106,"identity":"c998a2f9-7bdf-445f-b406-40ffcf16613b","added_by":"auto","created_at":"2025-09-23 15:42:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":186416,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrisma flow chart for the selection of studies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7614524/v1/49d65a71239f1fc0df063ad2.png"},{"id":102235487,"identity":"6d80ef83-f259-46ae-bc0f-175181c44440","added_by":"auto","created_at":"2026-02-09 16:16:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1530685,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7614524/v1/dbdd8765-dd64-416e-b0d3-55e92a6b4261.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of xerostomia on dental treatment outcomes: a systematic review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eXerostomia, commonly referred to as dry mouth, is the subjective sensation of oral dryness and is frequently associated with reduced salivary flow (hyposalivation) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Notably, some individuals experience xerostomic symptoms despite having normal salivary function, a condition described as \u0026ldquo;symptomatic\u0026rdquo; or \u0026ldquo;pseudo\u0026rdquo; xerostomia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The condition most often arises from diminished salivary secretion, which compromises the natural lubrication of the oral mucosa and affects overall oral health [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Xerostomia can affect people of all ages but is particularly common among postmenopausal women and older adults [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe causes of xerostomia are diverse. Medication-induced salivary dysfunction is the most frequent etiology, with drug classes such as anticholinergics, antidepressants, antipsychotics, diuretics, antihypertensives, sedatives, muscle relaxants, opioids, NSAIDs, and antihistamines often implicated [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Radiation therapy for head and neck cancers almost universally leads to xerostomia, as exposure of the parotid glands to doses above 24\u0026ndash;26 Gy causes irreversible glandular damage and long-term hyposalivation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Another well-recognized cause is Sj\u0026ouml;gren\u0026rsquo;s syndrome, an autoimmune disease that destroys salivary and lacrimal glands, most often affecting women over the age of 40 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Other systemic conditions such as diabetes mellitus, systemic lupus erythematosus, thyroid disorders, HIV/AIDS, end-stage renal disease, and graft-versus-host disease, as well as lifestyle factors including chronic mouth breathing and dehydration, may also contribute [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSaliva plays a vital role in oral health, with daily secretion ranging from 0.5 to 1.5 liters and containing electrolytes, proteins, enzymes, and antimicrobial agents [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It facilitates lubrication, mastication, swallowing, and digestion; contributes to buffering and remineralization; maintains a balanced oral microbiome; and supports tissue repair [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. When salivary flow is compromised, patients are predisposed to complications such as mucosal irritation, infection, oral dysbiosis, and impaired wound healing [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese pathophysiological changes have important implications for dental care. In restorative dentistry, xerostomia accelerates secondary caries and increases restoration failure rates, with studies noting reduced survival of glass ionomer and composite fillings in affected patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In prosthodontics, the absence of salivary lubrication impairs denture retention and comfort and also periodontal therapy may be less effective due to reduced mucosal defense, while in oral surgery, healing complications such as dry socket are more frequent, particularly among patients with comorbidities like diabetes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, peri-implant bone resorption may be accelerated by heightened mucosal inflammation and osteoclast activity in xerostomic patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Reduced saliva flow or altered saliva quality can harm teeth, hinder bone integration, and affect peri-implant health [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In scleroderma and Sj\u0026ouml;gren\u0026rsquo;s syndrome, this often leads to greater bone loss and soft tissue changes around implants [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the growing body of literature describing these effects, there remains no comprehensive synthesis evaluating the impact of xerostomia across dental treatment modalities. This knowledge gap limits clinical awareness and evidence-based decision-making for affected patients. A systematic review is therefore warranted to consolidate current evidence, highlight gaps, and guide strategies to optimize dental treatment outcomes in patients with xerostomia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe following systematic review was conducted in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and is registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD420251035790.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eFocused question\u003c/h2\u003e\u003cp\u003eThe question was defined in accordance with the Population, Intervention, Comparison, Outcome method (PICO) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. What are the clinical outcomes of dental treatment carried out in patients with xerostomia ?\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePrimary Outcome\u003c/h3\u003e\n\u003cp\u003eDental restoration failure, prosthetic instability, implant failure, periodontal treatment outcomes, caries recurrence, wound healing\u003c/p\u003e\n\u003ch3\u003eSecondary outcome\u003c/h3\u003e\n\u003cp\u003ePatient-reported outcomes (pain, discomfort, quality of life), treatment modifications or retreatments.\u003c/p\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003ePublications were eligible for inclusion if they involved human subjects with xerostomia or hyposalivation of any etiology, including Sj\u0026ouml;gren\u0026rsquo;s syndrome, medication-induced xerostomia, radiation-induced xerostomia, or systemic disease\u0026ndash;related salivary dysfunction. Studies were required to report at least one dental treatment outcome, such as restoration longevity, implant survival, periodontal healing, prosthesis retention, or patient-reported oral health\u0026ndash;related quality of life. Eligible designs included randomized controlled trials, cohort studies, case-control studies, and cross-sectional studies, provided that sufficient quantitative or qualitative outcome data were available. Only full-text articles published in English were considered.\u003c/p\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003eExclusion criteria were animal or in vitro studies, narrative reviews, systematic reviews, meta-analyses, conference abstracts without complete data, and case reports or case series with fewer than five patients. Studies focusing solely on xerostomia prevalence, pathophysiology, or pharmacologic management without reference to dental treatment outcomes were excluded. Likewise, publications unrelated to conventional dental implants or restorative/prosthetic therapy, as well as non-English language reports, were not considered.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eSearch strategy\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSearch strategy according to the focused question (PICO)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFocused Question (PICO)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eWhat are the clinical outcomes of dental treatment carried out in patient with xerostomia\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eSearch strategy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePopulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients with xerostomia or hyposalivation of any etiology (e.g., Sj\u0026ouml;gren\u0026rsquo;s syndrome, medication-induced, radiation-induced, systemic disease)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDental treatments, including restorative procedures, implant placement, periodontal therapy, and prosthodontic rehabilitation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparisons\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients without xerostomia, alternative dental materials or interventions, or within-patient comparisons (when applicable).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRestoration longevity/failure, implant survival, periodontal healing, prosthesis retention/stability, and patient-reported oral health\u0026ndash;related quality of life\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWe conducted a comprehensive search of the literature in three electronic databases: PubMed, Embase, and Google Scholar, to identify relevant studies reporting clinical outcomes of dental treatments in adults (\u0026ge;\u0026thinsp;18 years) with xerostomia, including those with Sj\u0026ouml;gren\u0026rsquo;s syndrome or other etiologies of dry mouth. The search included both controlled vocabulary terms (MeSH and Emtree) and free-text keywords to capture a broad range of studies.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePubMed\u003c/h3\u003e\n\u003cp\u003eThe PubMed search strategy combined MeSH terms and text words related to xerostomia and Sj\u0026ouml;gren\u0026rsquo;s syndrome, dental procedures, and treatment outcomes. The full search strategy was:\u003c/p\u003e\u003cp\u003e(\"Xerostomia\"[Mesh] OR \"Sj\u0026ouml;gren's Syndrome\"[tiab] OR \"Sicca Syndrome\"[tiab] OR xerostomia[tiab] OR \"dry mouth\"[tiab]) AND\u003c/p\u003e\u003cp\u003e(\"Dental Care\"[Mesh] OR \"Dental Implants\"[Mesh] OR \"Endodontics\"[Mesh] OR \"Tooth Extraction\"[Mesh] OR \"Prosthodontics\"[Mesh] OR dental treatment*[tiab] OR dental procedure*[tiab] OR dental implant*[tiab] OR tooth extraction*[tiab] OR exodontia*[tiab] OR periodontal therap*[tiab] OR \u0026ldquo;restoration*[tiab]) AND\u003c/p\u003e\u003cp\u003e(\"Treatment Outcome\"[Mesh] OR \"Postoperative Complications\"[Mesh] OR \"Wound Healing\"[Mesh] OR \"Recurrence\"[Mesh] OR \"Dental Restoration Failure\"[Mesh] OR treatment outcome*[tiab] OR complication*[tiab] OR dental implant failure[tiab] OR implant failure[tiab] OR recurrence[tiab] OR failure[tiab] OR healing[tiab])\u003c/p\u003e\u003cp\u003eFilters applied: Humans, English language, adults (\u0026ge;\u0026thinsp;18 years).\u003c/p\u003e\n\u003ch3\u003eEmbase\u003c/h3\u003e\n\u003cp\u003eThe Embase search used Emtree terms and text words:\u003c/p\u003e\u003cp\u003e('xerostomia'/exp OR 'xerostomia':ti,ab OR 'dry mouth':ti,ab OR 'sjogren syndrome':ti,ab OR 'sicca syndrome':ti,ab) AND\u003c/p\u003e\u003cp\u003e('dental care'/exp OR 'dental implant'/exp OR 'endodontics'/exp OR 'tooth extraction'/exp OR 'prosthodontics'/exp OR 'dental treatment*':ti,ab OR 'dental procedure*':ti,ab OR 'dental implant*':ti,ab OR 'tooth extraction*':ti,ab OR 'exodontia*':ti,ab OR 'periodontal therap*':ti,ab) AND\u003c/p\u003e\u003cp\u003e('treatment outcome'/exp OR 'postoperative complication'/exp OR 'wound healing'/exp OR 'recurrence'/exp OR 'dental restoration failure'/exp OR 'treatment outcome*':ti,ab OR 'complication*':ti,ab OR 'implant failure':ti,ab OR 'dental implant failure':ti,ab OR 'recurrence':ti,ab OR 'healing':ti,ab OR 'failure':ti,ab)\u003c/p\u003e\u003cp\u003eFilters applied: Humans, English language, adults (\u0026ge;\u0026thinsp;18 years).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eGoogle Scholar\u003c/h2\u003e\u003cp\u003eA simplified search was performed on Google Scholar using the terms:\u003c/p\u003e\u003cp\u003e(\"xerostomia\" OR \"dry mouth\" OR \"sjogren's syndrome\") AND\u003c/p\u003e\u003cp\u003e(\"dental treatment\" OR \"dental procedure\" OR \"implant\" OR \"restoration\" OR \"tooth extraction\") AND\u003c/p\u003e\u003cp\u003e(\"treatment outcome\" OR \"complication\" OR \"healing\" OR \"recurrence\" OR \u0026ldquo;failure\u0026rdquo;)\u003c/p\u003e\u003cp\u003eThe first 200 results were screened manually in incognito mode to reduce personalization bias.\u003c/p\u003e\u003cp\u003eReference lists of included studies were also screened to identify any additional relevant studies.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eStudy Selection\u003c/h2\u003e\u003cp\u003eTwo independent reviewers (S.P, P.K) screened titles and abstracts of retrieved studies for eligibility. Full-text articles of potentially relevant studies was assessed for inclusion. Discrepancies between reviewers was resolved through discussion or consultation with a third reviewer (P.P). The selection process was documented using a PRISMA flow diagram.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eData Extraction\u003c/h2\u003e\u003cp\u003eData from included studies was extracted independently by two reviewers (S.P, P.K) using a standardized data extraction form. Extracted data included: Study characteristics (author, year, country, study design), participant characteristics (age, gender, xerostomia diagnosis method), details of dental treatment(s) performed, outcomes measured and results, funding sources and conflicts of interest.\u003c/p\u003e\u003cp\u003e Any disagreements was resolved through discussion or consultation with a third reviewer (P.P). Authors of included studies were contacted for missing or unclear data.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eEthical considerations\u003c/h2\u003e\u003cp\u003eNo personal information of patients was used in this systematic review. All data was extracted from publicly available scientific publications. No informed consent or ethical approval was required for this systematic review.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eRisk of bias assessment\u003c/h2\u003e\u003cp\u003eThe risk of bias in included studies was assessed independently by two reviewers (S.P, P.K):\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eRandomized Controlled Trials: Cochrane Risk of Bias Tool (RoB 2) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNon-Randomized Studies: ROBINS-I (Risk Of Bias In Non-randomized Studies \u0026ndash; of Interventions) tool [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e Discrepancies was resolved through discussion or consultation with a third reviewer (P.P).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eCertainty of Evidence\u003c/h2\u003e\u003cp\u003eThe certainty of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Each outcome was rated as high, moderate, low, or very low certainty. Two reviewers (S.P, P.K) independently conducted the GRADE assessments, with discrepancies resolved through discussion or consultation with a third reviewer (P.P).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\u003ch2\u003eLiterature search\u003c/h2\u003e\u003cp\u003eA comprehensive literature search identified 244 records through electronic databases. After removing 27 duplicates, 217 unique records remained. Following title and abstract screening, 175 articles were excluded for irrelevance. Full-text screening was conducted for 15 articles, of which 18 studies were ultimately included in the review (12 from the database search and an additional 6 identified through reference screening).\u003c/p\u003e\u003cp\u003eDuring the full-text assessment, 8 publications were excluded because they were case reports or case series with fewer than five cases, which did not meet the predefined inclusion criteria. Other reasons for exclusion included insufficient outcome reporting and studies unrelated to dental treatment outcomes in xerostomia.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStudy characteristics\u003c/h2\u003e\u003cp\u003eThe characteristics of the included studies are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. One randomized controlled trial, one non-randomized interventional trial, five prospective cohort studies, seven retrospective cohort studies and two cross-sectional studies were included in the present systematic review.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults of literature search\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudy (Year)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDesign (N)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eXerostomia cause\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention (Comparator)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eKey findings\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBidyasgagar et al., 2023 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetrospective cohort (N\u0026thinsp;=\u0026thinsp;100; 50 xerostomia, 50 control)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot specified (medically compromised vs healthy)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDental implants (vs healthy controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigher implant failure in xerostomia group (10% vs 0%) and more tooth loss.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKaur et al., 2018 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-randomized interventional (N\u0026thinsp;=\u0026thinsp;60; 24 pSS, 36 controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary Sj\u0026ouml;gren\u0026rsquo;s syndrome (pSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePeriodontal therapy (SRP) (vs nose-breathing controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003epSS group had significantly lower plaque and gingival indices at 12 weeks (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbrecht et al., 2016 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCohort (N\u0026thinsp;=\u0026thinsp;292; 205 Sj\u0026ouml;gren\u0026rsquo;s [76% pSS], 87 controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSj\u0026ouml;gren\u0026rsquo;s syndrome (mixed pSS/sSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDental implants (vs healthy controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eImplant survival\u0026thinsp;~\u0026thinsp;100% in both groups; no difference in bone loss or failure rates.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIsidor et al., 1999 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProspective (N\u0026thinsp;=\u0026thinsp;8; all pSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary Sj\u0026ouml;gren\u0026rsquo;s syndrome (pSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSingle implant-supported crowns (no control)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13% implant failure; all remaining implants functioned at ~\u0026thinsp;3 years, high patient satisfaction.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHosseini et al., 2025 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProspective (N\u0026thinsp;=\u0026thinsp;47; 23 pSS, 24 controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary Sj\u0026ouml;gren\u0026rsquo;s syndrome (pSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eImplant-supported overdentures (vs controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e100% implant survival in both groups; no significant differences in bone loss or probing depths.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEttl et al., 2016 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProspective (N\u0026thinsp;=\u0026thinsp;29 patients; 165 implants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedication/radiation-induced xerostomia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDental implants (no control group)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% implant survival at 1 year, 94% at 5 years; xerostomia not a significant factor for success.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePetrovic et al., 2019 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMixed retrospective/prospective (N\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary Sj\u0026ouml;gren\u0026rsquo;s syndrome (pSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFibula graft oral rehabilitation (implants) (no control)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean oral function\u0026thinsp;~\u0026thinsp;64% of normal; recovery similar with or without pSS.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeinonen et al., 2021 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetrospective cohort (N\u0026thinsp;=\u0026thinsp;213; 71 pSS, 142 controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary Sj\u0026ouml;gren\u0026rsquo;s syndrome (pSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDental restorations (various) (vs non-SS controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eXerostomia patients had higher restoration failure (hazard ratio\u0026thinsp;\u0026asymp;\u0026thinsp;2.6 vs controls, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeMoor et al., 2011 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProspective controlled trial (N\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRadiation-induced xerostomia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eClass V restorations (GIC vs RMGIC vs composite)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGlass ionomer restorations had significantly fewer recurrent caries than composite/RMGIC (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMcComb et al., 2002 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRandomized trial (N\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRadiation-induced xerostomia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eClass V restorations (GIC vs RMGIC vs composite; within-patient comparison)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo overall significant differences; composite failed more often in non-fluoride users.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSparrow et al., 2021 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetrospective (N\u0026thinsp;=\u0026thinsp;119; 34 pSS/sSS, 85 controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSj\u0026ouml;gren\u0026rsquo;s syndrome (pSS/sSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePeriodontal maintenance (SRP) (vs non-xerostomia controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo significant differences in probing depth reduction or other indices between groups.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaarse et al., 2022 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProspective cohort (N\u0026thinsp;=\u0026thinsp;34; 17 pSS/sSS, 17 controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSj\u0026ouml;gren\u0026rsquo;s syndrome (pSS/sSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDental implants (vs age/sex-matched controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eImplant survival 100% (SS) vs 96% (controls, p\u0026thinsp;=\u0026thinsp;0.06); SS patients had more peri-implant mucositis.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSiddiqui et al., 2017 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetrospective EDR (N\u0026thinsp;=\u0026thinsp;180 SS patients)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eXerostomia (likely Sj\u0026ouml;gren\u0026rsquo;s)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVarious dental treatments (vs healthy controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eXerostomia patients had more dental treatments; implant survival 87.6% vs 95.7% in controls (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGomez et al., 2024 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetrospective EDR/EHR (N\u0026thinsp;=\u0026thinsp;144; 102 pSS, 42 controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary Sj\u0026ouml;gren\u0026rsquo;s syndrome (pSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMulti-surface restorations (vs controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigher restoration failure in pSS (HR\u0026thinsp;\u0026asymp;\u0026thinsp;2.9, 95% CI 2.3\u0026ndash;3.7); failures occurred\u0026thinsp;~\u0026thinsp;1 year sooner than controls.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKorfage et al., 2015 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetrospective cohort (N\u0026thinsp;=\u0026thinsp;100; 50 pSS, 50 controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary Sj\u0026ouml;gren\u0026rsquo;s syndrome (pSS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDental implants (vs controls)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eImplant survival 97% (pSS) vs 100% (controls, ns); SS had worse peri-implant plaque but similar clinical outcomes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaveman et al., 2003 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparative interventional (N\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRadiation-induced xerostomia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eClass I/II restorations (amalgam vs RMGIC; fluoride vs non-user)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFluoride users had no recurrent caries; among non-users, composite had more failures than GIC (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Sample sizes ranged widely, from fewer than 10 participants (8) in early implant rehabilitation case series to 290 patients. The study populations represented multiple xerostomia etiologies, including primary and secondary Sj\u0026ouml;gren\u0026rsquo;s syndrome, post\u0026ndash;head and neck radiotherapy, medication-induced hyposalivation, and mouth breathing. Participants were typically middle-aged or older adults (mean ages 50\u0026ndash;70 years), with women comprising the majority in Sj\u0026ouml;gren\u0026rsquo;s cohorts, while sex distribution was more balanced in general restorative or periodontal studies.\u003c/p\u003e\u003cp\u003eThe dental interventions evaluated fell into four broad categories: dental implants (survival of crowns, overdentures, full-arch prostheses), restorative treatments (composite/GIC fillings, crowns), periodontal therapy (scaling/root planing) and reconstructive surgery (mandibulectomy followed by reconstruction). Implant studies often used matched healthy controls (e.g. pSS vs control), whereas restorative trials compared materials within xerostomic patients (often stratified by fluoride use). Follow-up durations varied widely, ranging from several weeks (periodontal healing studies) to 2\u0026ndash;5 years (implant and restorative studies). Due to substantial heterogeneity in study design, outcome measures, and xerostomia etiologies, a formal meta-analysis could not be performed.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eLiterature analysis\u003c/h2\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003eRestoration survival/failure\u003c/h2\u003e\u003cp\u003eFive studies evaluated restoration outcomes in xerostomia. Large cohort studies (Leinonen 2021; Gomez 2024) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] consistently demonstrated higher failure rates among xerostomic patients compared with controls (HR\u0026thinsp;~\u0026thinsp;2\u0026ndash;3). Material-specific trials in radiation-induced xerostomia favored fluoride-releasing glass ionomer cements (GIC) over composite or amalgam. McComb (2002) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and De Moor (2011) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] both found that GIC significantly reduced recurrent caries compared with resin composites, although GIC showed greater marginal erosion. Haveman (2003) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] similarly reported no recurrent caries in fluoride users regardless of material, but in fluoride non-users eight amalgam restorations and one RMGI failed from recurrent caries, while some conventional GIC failed due to material loss. Overall, xerostomia increased restoration failure risk, and fluoride-releasing materials performed better than composites or amalgam. The certainty of evidence was low.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eImplant survival/success\u003c/h2\u003e\u003cp\u003eEight cohort studies (\u0026asymp;\u0026thinsp;300 implants) assessed implant survival in xerostomic patients. Across Sj\u0026ouml;gren\u0026rsquo;s cohorts (Maarse 2022; Hosseini 2025; Korfage 2015) [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], survival ranged from 97% to 100% at 18 months to 5 years, comparable to controls. Quality-of-life consistently improved following implant rehabilitation. In contrast, radiation-induced xerostomia was associated with earlier failures. Ettl (2016) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] reported implant losses within the first year post-radiotherapy, and Albrecht (2016)(24) observed higher failure prevalence in Sj\u0026ouml;gren\u0026rsquo;s (4.8%) versus controls (0%). Siddiqui (2017) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] reported 87% survival at ~\u0026thinsp;40 months, and Bidyasagar (2023) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] described failures in medically compromised groups that included xerostomia. Overall implant survival averaged\u0026thinsp;~\u0026thinsp;94%, with moderate certainty evidence, though radiation-induced xerostomia appeared to carry higher risk.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003ePeriodontal outcomes\u003c/h2\u003e\u003cp\u003eTwo studies assessed periodontal treatment response in xerostomia proxies. Kaur (2018) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] found that mouth-breathing patients had slower early improvement in gingival and bleeding indices after scaling and root planing, though outcomes equalized by 12 weeks. Sparrow (2021) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] reported similar probing depths and plaque scores between xerostomic and non-xerostomic patients during long-term maintenance. Evidence suggested xerostomia may delay short-term healing but not long-term outcomes. Certainty was low.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003ePatient-reported outcomes\u003c/h2\u003e\u003cp\u003eSix studies investigated patient-centered measures. Isidor (1999) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] demonstrated improved prosthesis comfort, chewing ability, and self-confidence with implant-retained dentures in Sj\u0026ouml;gren\u0026rsquo;s patients. Hosseini (2025) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and Maarse (2022) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] showed that OHRQoL improved significantly in both xerostomia and control groups, though scores remained lower in Sj\u0026ouml;gren\u0026rsquo;s across follow-up. Tobias ] and Korfage [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] similarly reported significant functional gains, including chewing, swallowing, and social eating. Petrovic (2019) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] reported overall worse asthetic outcomes in patients with post-radiotherapy xerostomia who under rehabilitation after mandibulectomy.\u003c/p\u003e\u003cp\u003eOverall, xerostomic patients reported meaningful improvement after dental rehabilitation, though baseline and post-treatment QoL remained lower than in controls. Certainty was low.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eProsthesis retention\u003c/h2\u003e\u003cp\u003eOne small study (Isidor 1999; n\u0026thinsp;=\u0026thinsp;8 Sj\u0026ouml;gren\u0026rsquo;s patients) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] directly assessed prosthesis retention. No implant-retained dentures were lost or remade over two years despite severe dryness. Evidence for this outcome remains very limited (very low certainty).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eRisk of bias assessment\u003c/h2\u003e\u003cp\u003eOverall, the risk of bias was high to serious for most included studies, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The single randomized controlled trial (McComb 2002) had high risk due to inadequate reporting of randomization, lack of blinding, and incomplete outcome data. All non-randomized studies were assessed using the ROBINS-I tool, with most rated as \u0026ldquo;serious\u0026rdquo; risk of bias primarily from confounding (e.g., differences in systemic conditions, medication use, or radiation exposure) and selection bias, while outcome measurement was generally objective and consistently reported. A few prospective cohorts (e.g., Maarse 2022, Hosseini 2025) had moderate risk, supported by clearer protocols and more complete follow-up, but residual confounding remained a concern.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRisk of Bias (RoB 2.0) for Randomized Controlled Trial(s)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudy (Author\u0026ndash;Year)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRandomization process\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDeviations from intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMissing outcome data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOutcome measurement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSelective reporting\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOverall RoB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eRationale (short)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMcComb 2002 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh risk \u0026mdash; insufficient reporting of random sequence generation and allocation concealment (abstract/limited methods).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow / Some concerns \u0026mdash; interventions delivered as intended within patients (split-mouth), but no blinding described.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSome concerns \u0026mdash; attrition reported (losses to follow-up), numbers not fully detailed in abstract.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSome concerns \u0026mdash; outcomes (secondary caries, marginal integrity) are objective but assessments likely unblinded.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSome concerns \u0026mdash; limited reporting detail in available record (full methods/results not fully described).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eRandomization and allocation concealment not clearly described; small sample and incomplete reporting increase risk of bias and limit confidence.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eCertainty of evidence assessment\u003c/h2\u003e\u003cp\u003eThe certainty of evidence, graded using the GRADE approach as shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e, was low to very low for most outcomes, reflecting the predominance of small, non-randomized studies with methodological limitations. Evidence on implant survival in xerostomic patients was judged moderate certainty, as results were consistent across several cohorts with survival rates\u0026thinsp;\u0026gt;\u0026thinsp;90% despite different xerostomia etiologies, though confounding and limited long-term follow-up reduced confidence. In contrast, evidence on restoration survival and periodontal treatment outcomes was of low to very low certainty, due to high risk of bias, small sample sizes, and heterogeneity in interventions and outcome definitions. No direct data were available on denture/prosthesis retention, leaving certainty as \u0026ldquo;very low.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRisk of Bias (ROBINS-I) for non-randomized studies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudy (Author\u0026ndash;Year)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConfounding\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelection of participants\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention classification\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDeviations from intended interventions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMissing data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOutcome measurement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSelective reporting\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eOverall ROBINS-I\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eRationale (short)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBidyasagar 2023 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; groups (compromised vs healthy) inherently confounded by comorbidities (e.g., diabetes).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate \u0026mdash; retrospective chart sampling; inclusion criteria not fully defined.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; implant exposure clearly recorded.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; same implant procedures across groups.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow \u0026mdash; 1-yr follow-up reported for all implants.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLow \u0026mdash; implant failure objectively defined (loss/MBL).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow \u0026mdash; main outcomes reported.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSerious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eRetrospective non-random grouping by health status with no adjustment for key confounders; objective outcomes but limited adjustment.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKaur 2018 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; mouth-breathing (proxy for xerostomia) can be associated with other baseline differences.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate \u0026mdash; selection unclear (convenience sample).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; SRP applied consistently.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; no differential deviations reported.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSome concerns \u0026mdash; small sample and some dropouts.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate \u0026mdash; clinical indices (BOP, PI) measured, but likely unblinded.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow \u0026mdash; reported as planned.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSerious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNon-random allocation by habit (mouth-breathers vs controls) and small sample increase risk of confounding and measurement bias.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbrecht 2016 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; baseline differences (age, oral health, meds) between SS and controls likely.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate \u0026mdash; cohort sampling likely adequate but non-contemporaneous controls used.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; implant exposure well defined.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; routine care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow \u0026mdash; follow-up reported.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate \u0026mdash; some outcomes self-reported; clinical indices varied.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow \u0026mdash; outcomes reported.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSerious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eLarge cohort but residual confounding from disease and medication; some patient-reported measures introduce measurement variability.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIsidor 1999 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; single-arm SS cohort; no concurrent controls.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate \u0026mdash; consecutive implant patients but small and selected.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; intervention clearly recorded.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; same protocol applied.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow \u0026mdash; short follow-up with few losses.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate \u0026mdash; objective survival, but examiners unblinded and small N.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSerious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSingle-arm prospective series without control group; high risk of confounding by indication and limited generalizability.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHosseini 2025 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate \u0026mdash; matching reduces confounding but residual differences remain (comorbidities).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow \u0026mdash; matched consecutive recruitment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; exposure clearly classified.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; standardized interventions.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModerate \u0026mdash; small attrition by 5 years but reported.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate \u0026mdash; clinical indices by single examiner (not blinded).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow \u0026mdash; outcomes fully reported.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eWell-conducted matched cohort but limited sample size and potential residual confounding; objective implant outcomes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEttl 2016 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; radiotherapy and cancer status confound outcomes; limited adjustment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow \u0026mdash; prospective cohort with clear inclusion.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; exposure (RT/no RT) recorded.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; standard care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow \u0026mdash; 1-yr follow-up complete.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLow\u0026ndash;Moderate \u0026mdash; implant survival objective; QoL subjective but validated.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eProspective design but major confounding by RT and cancer characteristics; outcomes largely objective but limited control of confounders.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePetrović 2019 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; heterogenous survivors (RT, trismus) introduce confounding.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSerious \u0026mdash; survivor recall and selection bias (25 subjects).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; intervention (fibula\u0026thinsp;+\u0026thinsp;rehabilitation) clearly identified.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; observational follow-up only.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModerate \u0026mdash; potential non-attendance and survival bias.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate \u0026mdash; outcomes (QoL, esthetics) subjective; multiple raters.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSerious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSmall, selected survivor cohort with likely survivorship/selection biases and subjective outcomes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeinonen 2021 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; residual confounding possible despite large registry; etiologies heterogeneous.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow\u0026ndash;Moderate\u0026mdash; registry sampling good but cause classification may be imperfect.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; restoration classification clear.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; no intended deviations.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow \u0026mdash; registry completeness good; attrition minimal.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLow \u0026mdash; objective restoration survival from records.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eModerate\u0026ndash;Serious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eLarge registry provides strong objective outcome data, but residual confounding and heterogeneity of xerostomia causes justify concern.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeMoor 2011 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate \u0026mdash; within-patient comparisons reduce confounding; allocation method unclear.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow \u0026mdash; patients required\u0026thinsp;\u0026ge;\u0026thinsp;3 restorations, selected.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; materials clearly assigned per site.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; interventions per protocol.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModerate \u0026mdash; some attrition by 24 months.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate \u0026mdash; restoration outcomes clinically assessed, examiners likely unblinded.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eProspective clinical design with split-mouth elements, but unclear random sequence and some attrition weaken internal validity.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSparrow 2021 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; mixed xerostomia etiologies and potential confounders (meds, baseline severity).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate \u0026mdash; convenience sample of maintenance patients.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; xerostomia classification via unstimulated flow was performed.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; maintenance delivered as routine.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow \u0026mdash; cross-sectional maintenance visit data complete.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate \u0026mdash; PD/PI measured but examiners not blinded.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eModerate\u0026ndash;Serious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eRetrospective maintenance assessment with objective outcomes but potential confounding by xerostomia etiology and unmeasured factors.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaarse 2022 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate \u0026mdash; group differences possible; mixed adjustments with mixed models.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow \u0026mdash; multicenter prospective inclusion with clear criteria.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; implant exposure clearly recorded.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; standardized surgical/restorative protocol across centers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow \u0026mdash; 18-month follow-up largely complete.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLow \u0026mdash; implant survival and MBL objectively measured.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eProspective multicenter design strengthens evidence but sample modest and residual confounding possible; objective outcomes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSiddiqui 2017 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; limited adjustment for disease severity, meds, or oral hygiene.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate\u0026ndash;Serious \u0026mdash; single-center EDR convenience sample; selection criteria incompletely described.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; interventions accurately captured in EDR.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; routine care delivered.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSome concerns \u0026mdash; missing baseline data and variable record completeness.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLow\u0026ndash;Moderate \u0026mdash; EDR outcome definitions pragmatic but may vary.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSerious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eLarge retrospective EDR study with objective outcomes, but substantial residual confounding and variable data completeness.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGomez 2024 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; residual confounding by meds, baseline caries risk, and behavior despite adjustment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate \u0026mdash; matched controls but retrospective selection may bias.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; restorations and exposures well classified.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; standard clinical care documented.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow \u0026mdash; survival/failure data available for most restorations.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLow \u0026mdash; restoration failure operationalized objectively.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSerious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eRobust EDR/EHR analysis but still susceptible to unmeasured confounders and imprecision in some subgroups.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKorfage 2015 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; SS patients differ in meds, disease activity vs historic controls.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSerious \u0026mdash; 19/69 eligible SS with implants did not undergo exam; controls historic.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; exposure recorded (implants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; standard care across centers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModerate \u0026mdash; baseline radiographs missing for ~\u0026thinsp;48% (MBL analysis affected).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate \u0026mdash; clinical indices measured by different examiners across groups.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSerious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSelection bias (non-participation), historic control matching, and missing baseline radiographs are major concerns for bone loss and peri-implant comparisons.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaveman 2003 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSerious \u0026mdash; very small N (9 patients) and fluoride compliance strongly confounds results.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSerious \u0026mdash; convenience sample with possible selection of severe cases.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow \u0026mdash; materials and grouping (fluoride users vs non-users) clearly described.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow \u0026mdash; restorative procedures as intended.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModerate \u0026mdash; 86% of restorations evaluated at 2 years (some loss to follow-up).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate \u0026mdash; caries assessment clinical and photographic, but assessor not blinded; outcome clustering by patient.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSerious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSmall sample, strong confounding by fluoride compliance and patient-level clustering; limits generalizability despite objective outcomes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCertainty assessment of the study outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudies (total N)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCertainty (GRADE)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eComments (downgrading factors)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImplant survival/success\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 studies (observational data)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEvidence from non-randomized studies; downgraded for risk of bias and imprecision, but results were generally consistent with good implant survival.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRestoration survival/failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 studies (observational)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eObservational evidence; heterogeneity in materials and patient causes; wide confidence intervals. Downgraded for bias, inconsistency, imprecision.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeriodontal outcomes (e.g. PD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 studies (observational)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFew small studies; evidence limited to adult xerostomia (mainly Sj\u0026ouml;gren\u0026rsquo;s). Downgraded for risk of bias and imprecision.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient-reported outcomes (QoL, comfort)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 studies (observational)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConsistent improvements reported after treatment, but only small cohort data. Downgraded for bias (non-randomized) and imprecision.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eRestoration outcomes\u003c/h2\u003e\u003cp\u003ePatients with xerostomia, or dry mouth, are at increased risk for dental caries because of the loss of saliva and its protective functions [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. A reduction in salivary flow increases oral acidity and promotes proliferation of acidogenic bacteria, while impairing buffering capacity, mineral replenishment, and lubrication of tooth surfaces [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Together, these factors accelerate caries development and compromise restoration longevity [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConsistent with this biological plausibility, retrospective cohort studies show that xerostomic patients often lose restorations earlier than non-xerostomic controls. Gomez et al. (2024) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] reported that patients with Sj\u0026ouml;gren\u0026rsquo;s syndrome had nearly three-fold higher risk of restoration failure (hazard ratio\u0026thinsp;~\u0026thinsp;3.0) compared to matched controls, with five-year survival rates of ~\u0026thinsp;55% versus ~\u0026thinsp;75%. Leinonen et al. (2021) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] similarly observed shorter survival of restorations in Sj\u0026ouml;gren\u0026rsquo;s and radiotherapy-induced xerostomia compared with patients who had hyposalivation of unspecified origin. The authors suggested that poorer saliva quality, trismus, and mucosal sensitivity in these groups may hinder oral hygiene and further reduce restoration longevity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFailures were most often due to recurrent caries at restoration margins, a finding supported by other caries risk studies in xerostomia [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Several small clinical trials have evaluated material choice. Haveman et al. (2003) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] found that glass ionomer\u0026ndash;based materials reduced recurrent caries compared with amalgam in fluoride non-users, although conventional GIC showed some erosion-related failures. Importantly, the study was limited by very small sample size and confounding by fluoride compliance. The authors nevertheless highlighted the potential advantage of fluoride-releasing materials in radiation-induced xerostomia, though larger controlled trials are needed.\u003c/p\u003e\u003cp\u003eAn earlier trial by Wood et al. (1993) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] placed paired restorations in 36 xerostomic head and neck cancer patients. Results showed a striking interaction with fluoride use: in fluoride users, glass ionomer cement failed while amalgam survived, whereas in non-users, the opposite occurred (glass ionomer survived, amalgam failed). Mean time to failure was 8.5 months, with more pronounced effects in severely xerostomic patients.\u003c/p\u003e\u003cp\u003eTaken together, these studies suggest that xerostomia substantially increases restoration failure risk, largely through recurrent caries. Material selection appears important: fluoride-releasing cements may be advantageous in patients with poor fluoride compliance, while amalgam performs better when topical fluoride is used regularly. However, evidence is limited, heterogeneous, and of low certainty, underscoring the need for well-designed trials to guide restorative choices in xerostomic patients.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eImplant survival/success\u003c/h3\u003e\n\u003cp\u003eMost included studies demonstrated that implant therapy in patients with Sj\u0026ouml;gren\u0026rsquo;s syndrome yields survival rates comparable to non-xerostomic controls, typically above 94% over 3\u0026ndash;5 years. Quality-of-life improvements were consistent, with patients reporting better function, comfort, and oral health-related quality of life (OHRQoL) after rehabilitation [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. These results align with systematic reviews in healthy populations, which report 10-year implant survival rates of 95\u0026ndash;97% [\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, outcomes were notably poorer in radiation-induced xerostomia. Failures occurred within the first year after therapy, contrasting with the more gradual failures in Sj\u0026ouml;gren\u0026rsquo;s syndrome. Radiation likely damages endothelial cells and microvasculature, producing chronic ischemia and impaired osseointegration. These mechanisms may explain why radiation-induced xerostomia carries a higher implant failure risk [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOverall, implants remain a viable option in xerostomia, especially for autoimmune etiologies, but patient selection and management of systemic factors are crucial.\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003ePeriodontal outcomes\u003c/h2\u003e\u003cp\u003eXerostomia reduces salivary clearance and increases plaque accumulation, leading to greater gingival inflammation and higher periodontitis risk [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Consistent with this, Kaur et al. (2018) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] found that mouth-breathing patients had delayed early improvement in gingival indices following scaling and root planing compared with nasal breathers. By contrast, Sparrow et al. (2021) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] observed that xerostomic patients maintained similar probing depths and plaque control to non-xerostomic controls over long-term maintenance, provided recall visits and hygiene support were frequent.\u003c/p\u003e\u003cp\u003eThese findings suggest xerostomia may delay short-term healing but, with diligent maintenance, periodontal outcomes can eventually approximate those of controls. Evidence remains very limited, and certainty is low.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003ePatient outcomes\u003c/h2\u003e\u003cp\u003ePatient-centered outcomes consistently showed improvement after treatment. Studies of implant-supported prostheses in Sj\u0026ouml;gren\u0026rsquo;s patients reported significant improvements in chewing ability, swallowing, denture comfort, and overall OHRQoL (e.g., Maarse 2022; Hosseini 2025). However, baseline and post-treatment QoL remained worse in xerostomia patients compared with controls. Direct evidence for prosthesis retention was scarce; only one small study (Isidor 1999) showed stable implant-retained dentures over two years in xerostomic patients.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003cp\u003eThis review is limited by the generally low quality of evidence. Most included studies were retrospective or small prospective cohorts, with non-random group allocation, unblinded outcome assessment, and limited control for confounders. Sample sizes were often small, follow-up periods varied, and outcomes were heterogeneous across xerostomia etiologies, treatments, and measures. These issues contributed to wide confidence intervals and predominantly low-to-moderate certainty ratings using GRADE.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical implications\u003c/strong\u003e\u003cp\u003eXerostomia poses significant challenges for dental care, increasing caries risk and reducing restoration longevity. Preventive measures such as high-fluoride regimens, sealants, and frequent recall are essential. Resin-modified glass ionomers or moisture-tolerant materials may be preferred for restorations. Implant therapy generally shows good survival even in xerostomic patients, though careful case selection and systemic risk management are critical. Periodontal therapy can be effective with close maintenance, though early healing may be slower.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFuture research\u003c/strong\u003e\u003cp\u003eRobust prospective studies are needed, stratifying patients by xerostomia severity and cause, and employing standardized outcome measures and blinded assessment. Larger sample sizes and better control of confounders will allow stronger conclusions and meta-analysis. In particular, the lack of evidence on denture retention in xerostomia represents an important research gap. Future trials should also evaluate whether therapies for salivary stimulation or substitution can improve dental treatment outcomes.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eXerostomia appears to worsen the durability of dental restorations and may modestly challenge periodontal therapy, while implant-based prosthetic treatments remain generally successful. All rehabilitative treatments yielded patient-reported benefits. However, these conclusions rest on limited evidence with significant bias and imprecision. Clinicians should anticipate higher preventive and maintenance needs in xerostomia patients, and researchers should pursue robust trials to confirm and refine these findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePRISMA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eP\u0026ndash;Preferred Reporting Items for Systematic Review and Meta\u0026ndash;Analysis Protocols\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePROSPERO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Prospective Register of Systematic Reviews\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePICO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePopulation, Intervention, Comparison, Outcome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRandomized Controlled Trial\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRoB 2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCochrane Risk of Bias Tool, version 2\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eROBINS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eI\u0026ndash;Risk of Bias in Non\u0026ndash;randomized Studies\u0026ndash;of Interventions\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGRADE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGrading of Recommendations, Assessment, Development, and Evaluation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQoL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of Life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOHRQoL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOral Health\u0026ndash;Related Quality of Life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGIC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGlass Ionomer Cement\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRMGI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eResin\u0026ndash;Modified Glass Ionomer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data are included into the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrakash Kafle and Prativa Pandey had equal contribution in the work and share the second authorship.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, S.P.; methodology, S.P., P.K., and P.P.; software, P.K. and P.T.; validation, S.P. and S.G.; formal analysis, S.P., P.P., and A.B.; investigation, S.P. and A.B.; resources, P.T. and S.G.; data curation, S.P., P.K., and P.P.; writing—original draft preparation, S.P.; writing—review and editing, P.K., P.P., A.B., P.T., and S.G.; visualization, P.K. and P.P.; supervision, B.S.; project administration, S.P. and B.S. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was not required for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKapourani A, Kontogiannopoulos KN, Manioudaki AE, Poulopoulos AK, Tsalikis L, Assimopoulou AN et al. A Review on Xerostomia and Its Various Management Strategies: The Role of Advanced Polymeric Materials in the Treatment Approaches. Polymers (Basel) [Internet]. 2022 Feb 22 [cited 2025 Sept 14];14(5):850. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8912296/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8912296/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTalha B, Swarnkar SA. Xerostomia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 Sept 14]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK545287/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK545287/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuggenheimer J, Moore PA. Xerostomia: etiology, recognition and treatment. J Am Dent Assoc. 2003;134(1):61\u0026ndash;9. quiz 118\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJohansson AK, Johansson A, Unell L, Ekb\u0026auml;ck G, Ordell S, Carlsson GE. Self-reported dry mouth in 50- to 80-year-old Swedes: Longitudinal and cross-sectional population studies. J Oral Rehabil. 2020;47(2):246\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUchida H, Ovitt CE. Novel impacts of saliva with regard to oral health. J Prosthet Dent [Internet]. 2022 Mar [cited 2025 Sept 14];127(3):383\u0026ndash;91. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8669010/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8669010/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeinonen J, V\u0026auml;h\u0026auml;nikkil\u0026auml; H, Raninen E, J\u0026auml;rvelin L, N\u0026auml;p\u0026auml;nkangas R, Anttonen V. The survival time of restorations is shortened in patients with dry mouth. J Dent. 2021;113:103794.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrand HS, Ligtenberg AJM, Veerman ECI. Saliva and wound healing. Monogr Oral Sci. 2014;24:52\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCahyani SP, Maharani AT. Alfisa\u0026rsquo;ida \u0026lsquo;Aliyya, Tantiana. The effect of Xerostomia in diabetes mellitus patients on the incidence of dry socket after tooth extraction: A literature review. World Journal of Advanced Research and Reviews [Internet]. 2024 [cited 2025 Sept 14];24(1):1650\u0026ndash;5. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://wjarr.com/content/effect-xerostomia-diabetes-mellitus-patients-incidence-dry-socket-after-tooth-extraction\u003c/span\u003e\u003cspan address=\"https://wjarr.com/content/effect-xerostomia-diabetes-mellitus-patients-incidence-dry-socket-after-tooth-extraction\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHori Y, Kondo Y, Nodai T, Masaki C, Ono K, Hosokawa R. Xerostomia aggravates ligation-induced peri-implantitis: A preclinical in vivo study. Clinical Oral Implants Research [Internet]. 2021 [cited 2025 Sept 14];32(5):581\u0026ndash;9. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://onlinelibrary.wiley.com/doi/abs/\u003c/span\u003e\u003cspan address=\"https://onlinelibrary.wiley.com/doi/abs/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/clr.13727\u003c/span\u003e\u003cspan address=\"10.1111/clr.13727\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiz P, Scully C, Sanz M. Dental implants in the medically compromised patient. Journal of Dentistry [Internet]. 2013 Mar 1 [cited 2025 Sept 14];41(3):195\u0026ndash;206. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/science/article/pii/S0300571213000043\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/science/article/pii/S0300571213000043\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEriksen MB, Frandsen TF. The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search quality: a systematic review. J Med Libr Assoc. 2018;106(4):420\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHiggins JPT, Altman DG, G\u0026oslash;tzsche PC, J\u0026uuml;ni P, Moher D, Oxman AD et al. The Cochrane Collaboration\u0026rsquo;s tool for assessing risk of bias in randomised trials. BMJ [Internet]. 2011 Oct 18 [cited 2025 Sept 14];343:d5928. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bmj.com/content/343/bmj.d5928\u003c/span\u003e\u003cspan address=\"https://www.bmj.com/content/343/bmj.d5928\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSterne JA, Hern\u0026aacute;n MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ [Internet]. 2016 Oct 12 [cited 2025 Sept 14];355:i4919. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bmj.com/content/355/bmj.i4919\u003c/span\u003e\u003cspan address=\"https://www.bmj.com/content/355/bmj.i4919\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ [Internet]. 2008 Apr 24 [cited 2025 Sept 14];336(7650):924\u0026ndash;6. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bmj.com/content/336/7650/924\u003c/span\u003e\u003cspan address=\"https://www.bmj.com/content/336/7650/924\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGomez GGF, Wang M, Siddiqui ZA, Gonzalez T, Capin OR, Willis L, et al. Longevity of dental restorations in Sjogren\u0026rsquo;s disease patients using electronic dental and health record data. BMC Oral Health. 2024;24(1):203.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcComb D, Erickson RL, Maxymiw WG, Wood RE. A clinical comparison of glass ionomer, resin-modified glass ionomer and resin composite restorations in the treatment of cervical caries in xerostomic head and neck radiation patients. Oper Dent. 2002;27(5):430\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Moor RJG, Stassen IG, van \u0026rsquo;t Veldt Y, Torbeyns D, Hommez GMG. Two-year clinical performance of glass ionomer and resin composite restorations in xerostomic head- and neck-irradiated cancer patients. Clin Oral Investig. 2011;15(1):31\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaveman CW, Summitt JB, Burgess JO, Carlson K. Three restorative materials and topical fluoride gel used in xerostomic patients: a clinical comparison. J Am Dent Assoc. 2003;134(2):177\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaarse F, Fennis WMM, Twisk JWR, Korfage A, Santing HJ, den Hartog L, et al. Dental implants in dentate primary and secondary Sj\u0026ouml;gren\u0026rsquo;s syndrome patients: A multicenter prospective cohort study. Clin Oral Implants Res. 2022;33(11):1157\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHosseini M, Jensen SS, Gotfredsen K, Hyldahl E, Pedersen AML. Prognosis of Single Implant-Supported Prosthesis in Patients With Primary Sj\u0026ouml;gren\u0026rsquo;s Syndrome: A Five-Year Prospective Clinical Study. Clin Oral Implants Res. 2025;36(1):51\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKorfage A, Raghoebar GM, Arends S, Meiners PM, Visser A, Kroese FG, et al. Dental Implants in Patients with Sj\u0026ouml;gren\u0026rsquo;s Syndrome. Clin Implant Dent Relat Res. 2016;18(5):937\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEttl T, Weindler J, Gosau M, M\u0026uuml;ller S, Hautmann M, Zeman F et al. Impact of radiotherapy on implant-based prosthetic rehabilitation in patients with head and neck cancer: A prospective observational study on implant survival and quality of life\u0026mdash;Preliminary results. Journal of Cranio-Maxillofacial Surgery [Internet]. 2016 Sept 1 [cited 2025 Sept 14];44(9):1453\u0026ndash;62. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/science/article/pii/S1010518216301500\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/science/article/pii/S1010518216301500\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlbrecht K, Callhoff J, Westhoff G, Dietrich T, D\u0026ouml;rner T, Zink A. The Prevalence of Dental Implants and Related Factors in Patients with Sj\u0026ouml;gren Syndrome: Results from a Cohort Study. J Rheumatol. 2016 July;43(7):1380\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiddiqui Z, Wang Y, Makkad P, Thyvalikakath T. Characterizing Restorative Dental Treatments of Sj\u0026ouml;gren\u0026rsquo;s Syndrome Patients Using Electronic Dental Records Data. Stud Health Technol Inf. 2017;245:1166\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBidyasagar Bal SC, Awinashe VN, Jindal P, Khader AA, Almutairi FJ, Parihar AS, et al. Retrospective Analysis of Dental Implant Failure Rates in Patients with Compromised Health. J Pharm Bioallied Sci. 2023 July;15(Suppl 2):S1149\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaur M, Sharma RK, Tewari S, Narula SC. Influence of mouth breathing on outcome of scaling and root planing in chronic periodontitis. BDJ Open. 2018;4:17039.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSparrow TV, Fritz PC, Sullivan PJ, Ward WE. Regular maintenance appointments after non-surgical scaling and root planing support periodontal health in patients with or without dry mouth: A retrospective study. Clin Exp Dent Res. 2021;7(5):647\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIsidor F, Br\u0026oslash;ndum K, Hansen HJ, Jensen J, Sindet-Pedersen S. Outcome of treatment with implant-retained dental prostheses in patients with Sj\u0026ouml;gren syndrome. Int J Oral Maxillofac Implants. 1999;14(5):736\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePetrovic I, Baser R, Blackwell T, McCarthy C, Ganly I, Patel S, et al. Long-term functional and esthetic outcomes after fibula free flap reconstruction of the mandible. Head Neck. 2019 July;41(7):2123\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSu N, Marek CL, Ching V, Grushka M. Caries prevention for patients with dry mouth. J Can Dent Assoc. 2011;77:b85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChisini LA, Collares K, Cademartori MG, de Oliveira LJC, Conde MCM, Demarco FF, et al. Restorations in primary teeth: a systematic review on survival and reasons for failures. Int J Paediatr Dent. 2018;28(2):123\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWood RE, Maxymiw WG, McComb D. A clinical comparison of glass ionomer (polyalkenoate) and silver amalgam restorations in the treatment of Class 5 caries in xerostomic head and neck cancer patients. Oper Dent. 1993;18(3):94\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlmeida D, Vianna K, Arriaga P, Moraschini V. Dental implants in Sj\u0026ouml;gren\u0026rsquo;s syndrome patients: A systematic review. PLoS One [Internet]. 2017 Dec 14 [cited 2025 Sept 14];12(12):e0189507. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730117/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730117/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoraschini V, Poubel LA da, Ferreira C, Barboza VF. E dos SP. Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review. Int J Oral Maxillofac Surg. 2015;44(3):377\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHjalmarsson L, Gheisarifar M, Jemt T. A systematic review of survival of single implants as presented in longitudinal studies with a follow-up of at least 10 years. Eur J Oral Implantol. 2016;9(Suppl 1):S155\u0026ndash;162.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChrcanovic BR, Kisch J, Wennerberg A. Dental implants in patients with Sj\u0026ouml;gren\u0026rsquo;s syndrome: a case series and a systematic review. Int J Oral Maxillofac Surg. 2019 Sept;48(9):1250\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarx RE, Osteoradionecrosis. A new concept of its pathophysiology. Journal of Oral and Maxillofacial Surgery [Internet]. 1983 May 1 [cited 2025 Sept 14];41(5):283\u0026ndash;8. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.joms.org/article/0278-2391(83)90294-X/fulltext\u003c/span\u003e\u003cspan address=\"https://www.joms.org/article/0278-2391(83)90294-X/fulltext\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMizutani S, Ekuni D, Tomofuji T, Azuma T, Kataoka K, Yamane M, et al. Relationship between xerostomia and gingival condition in young adults. J Periodontal Res. 2015;50(1):74\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7614524/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7614524/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eXerostomia, commonly caused by medications, radiotherapy, or Sj\u0026ouml;gren\u0026rsquo;s syndrome, impairs saliva\u0026rsquo;s protective functions and increases risk of caries, restoration failure, prosthesis complications, and peri-implant bone loss. However, its overall impact on dental treatment outcomes has not been systematically reviewed.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e A systematic review was conducted following PRISMA guidelines. Electronic databases were searched, and studies evaluating the impact of xerostomia on dental treatment outcomes, including restorations, implants, prostheses, and periodontal therapy, were included. Data extraction was performed in duplicate, and risk of bias was assessed using RoB 2.0 for randomized trials and ROBINS-I for non-randomized studies. Certainty of evidence was graded using the GRADE approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSixteen studies were included in the review. Implant survival in xerostomic patients was generally high (\u0026gt;\u0026thinsp;90%) but slightly lower in those with radiation-induced xerostomia. Restoration longevity was consistently reduced, with higher failure and recurrent caries rates in Sj\u0026ouml;gren\u0026rsquo;s syndrome and post-radiotherapy patients. Limited evidence suggested no major differences in periodontal treatment response, while no eligible studies directly assessed denture retention. Overall, most studies were small, heterogeneous, and at moderate to serious risk of bias.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eXerostomia reduces restoration longevity and may affect periodontal therapy, while implants generally show good survival. Evidence is limited and biased, highlighting the need for preventive care and stronger clinical studies.\u003c/p\u003e","manuscriptTitle":"Impact of xerostomia on dental treatment outcomes: a systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 15:42:06","doi":"10.21203/rs.3.rs-7614524/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-16T04:57:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-30T19:25:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-28T06:59:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79321598122011774397434515354239629670","date":"2025-11-21T08:00:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261393377408628238108899965827776507685","date":"2025-11-13T21:43:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-06T20:04:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-30T14:17:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-30T14:16:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-09-14T20:05:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ceb4e001-5a3f-4f1c-8eff-90eb8f5a528a","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:16:08+00:00","versionOfRecord":{"articleIdentity":"rs-7614524","link":"https://doi.org/10.1186/s12903-026-07815-8","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2026-02-02 15:57:35","publishedOnDateReadable":"February 2nd, 2026"},"versionCreatedAt":"2025-09-23 15:42:06","video":"","vorDoi":"10.1186/s12903-026-07815-8","vorDoiUrl":"https://doi.org/10.1186/s12903-026-07815-8","workflowStages":[]},"version":"v1","identity":"rs-7614524","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7614524","identity":"rs-7614524","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}