- Case Report
Reprinted with permission,
Jan.-Feb. 1999 issue.
After reading the article below, the reader should be able to
describe techniques for the control of saliva during dental
procedures; discuss the problems associated with saliva
contamination of an operative field; explain the clinical
benefits, dosing guidelines, and contraindications for using
atropine sulfate to temporarily reduce saliva flow during dental
Exercise No. 67
for Self Instruction Questions.
Atropine sulfate -- a current review of a useful agent for
controlling salivation during dental procedures
Craig R. Sherman, MD
Beryl R. Sherman, DDS
The oral cavity is a particularly difficult place in which to
work. One challenge it presents is the nature and content of
saliva, which can complicate operating conditions by making
visibility difficult, leaving tooth surfaces wet, and
interfering with various procedures that involve adhesion or
bonding. Another challenge is salivary flow tends to increase
during dental procedures.
Dental clinicians have various methods for controlling moisture
during dental procedures, including cotton roll isolation,
saliva evacuators, and rubber dams. These traditional methods
are useful, but each has certain drawbacks and limitations.
Some clinicians, particularly orthodontists, use pharmaceutical
drying agents instead. Methantheline bromide and propantheline
bromide are two drying agents that have been used for decades,
but their variable effectiveness and systemic effects can be
problematic. In recent years, the American Dental Association
Council on Scientific Affairs approved atropine sulfate 0.4 mg
tablets as an alternative for effectively achieving moisture
control during dental procedures.
The necessity for maintaining a dry field during various dental
treatments is reviewed here, and we discuss various benefits
that atropine sulfate offers to both dentists and patients.
Consequences of Inadequate Moisture Control
Sufficient moisture control is crucial during many dental
procedures. In restorations, for instance, saliva contacting
with teeth can create mucinous deposits.1
If the saliva invades a cavity preparation or mixes with the
restorative material, it can affect the marginal adaptation,
hardness, and accuracy after setting. Silver amalgam is
particularly susceptible to moisture contamination, because such
contamination causes a severe, delayed expansion of the material
and a blister typically forms on the metal's surface. The dry
tooth surface is also important in such cases because it makes
it possible to clearly see and assess caries excavation and to
detect the presence of remaining caries, which has a
characteristic moist, leathery texture that can be more easily
distinguished in a dry field.1
Moisture control is also essential for endodontic procedures2
and for bonding orthodontic brackets successfully, as saliva
affects the ability of various bonding materials to adhere to
the tooth surfaces.3,4
Saliva contamination has also been shown to significantly
decrease the adhesive bond strength of some impression
During periodontal procedures, some researchers have theorized,
the protein-rich coating that saliva creates can interfere with
proper clot adhesion an important factor in reliable periodontal
In at least one in vitro study, saliva coating appeared
to inhibit the attachment and movement of gingival fibroblasts,
those cells needed to regenerate the periodontium, on tissue
culture plastic and on cementum.7
However, a small-scale in vivo study in dogs suggested
that saliva coating may not necessarily compromise connective
tissue reattachment to the tooth surface.6
Saliva contamination of the etched tooth surfaces has been cited
as the most frequent cause of failure for sealant adherence.8
Evans and Silverston found that as little as one second of
saliva contamination on the etched surfaces resulted in a
tenacious coating that blocked micropores in the enamel surface.
This may explain why saliva interferes with proper adherence. In
this study, washing did not appear to remove the coating for any
specimens except those exposed for a half-second or less.9
Traditional Options for Moisture Control
Clearly, maintaining a dry operative field is imperative to
achieving an acceptable result during many dental procedures.
Traditional methods of controlling saliva contamination in the
work area include cotton roll isolation, the use of a rubber
dam, and saliva evacuators. Cotton roll isolation involves
placing cylinders of cotton along the buccal mucosa and over the
parotid gland ducts. These are generally used in conjunction
with a high-speed saliva evacuator. Cotton roll isolation can be
useful, but clearly only for very short-term procedures since as
the cotton merely absorbs saliva. To be effective, cotton rolls
must be changed frequently. They also can be cumbersome to both
patients and the clinician.10
For longer procedures, rubber dams have traditionally been used.
The dam is made of latex and is punched to fit the teeth and
then placed around them to isolate the area from the oral
environment. Rubber dams can be a useful way to keep the area
dry, except for moisture inherent in the tooth structure. They
also partially retract the jaw. In many cases, their use
requires that the gingiva be anesthetized, which can make them
difficult to use for the pediatric patient.10 In general,
although rubber dams take extra time to prepare, they appear to
better control moisture than do cotton rolls.11
However, they are not foolproof.
In some cases, particularly those involving treatment of splint
or bridge abutments, rubber dams can fail to control saliva
seepage when dams cannot be tucked into the interproximal spaces
around the tooth being treated and when the shape of the crown
is not normal due to caries, loss of a restoration, or an
abnormal axial inclination.10
A third traditional method is the use of saliva evacuators.
These can be satisfactory, but nevertheless carry both the risk
of backflow and that of increasing tension and anxiety in the
For these reasons, some clinicians prefer to administer
pharmaceutical drying agents instead of, or in addition to, the
traditional methods. Methantheline bromide (Banthine, Searle &
Co., San Juan, Puerto Rico) was a medication used for treating
patients with peptic ulcers. A frequent side effect with this
medication was xerostomia. Although this dryness was tolerable
for brief dental procedures, medical patients taking the drug
for prolonged periods often complained of feeling parched and
would request alternate therapy.
Addressing the concerns of internists and their patients, the
manufacturer of methantheline replaced this drug with a new one
less likely to affect salivary secretions. Propantheline bromide
(Pro-Banthine, Searle & Co., San Juan, Puerto Rico) has proven
effective in the treatment of peptic ulcers; but, reports in the
dental literature indicate that its effectiveness as a drying
agent in dental applications is variable.12,13
Furthermore, safety of this new agent for pediatric patients has
not been established.14
Administration by sublingual injection instead of tablets tends
to increase the effectiveness in reducing salivary flow;
however, clinicians have been cautioned against the use of
sublingual injections for this purpose.3
Atropine Sulfate as an Adjunct to Traditional Methods
Atropine sulfate 0.4 mg tablets (Sal-Tropine, Hope
Pharmaceuticals, Scottsdale, Arizona) offers several advantages
over these various methods for maintaining adequate moisture
control. Like methantheline and propantheline, atropine is a
competitive antagonist of the muscarinic actions of
acetylcholine. Atropine blocks the attachment of acetylcholine
to receptors on the salivary glands; and consequently, the
glands are not stimulated to produce saliva. Intravenous
atropine sulfate (0.25 mg, 0.4 mg, 0.75 mg, and 1.5 mg) given to
72 healthy medical students was found to inhibit salivation at
Intramuscular and orally administered atropine sulfate also
inhibit salivation, but require higher doses.
Based on peak inhibition of salivation in one study, 0.9-1.4 mg
of orally administered drug was estimated to be approximately
equivalent in effect to 0.6 mg administered by intramuscular
This was confirmed in a second study in which the ratio of oral
to intramuscular doses of atropine sulfate on salivary secretion
Drug effect was further documented with the oral administration
of atropine sulfate to a patient with closed head injury and
significant drooling. Testing doses between 0.3 and 1.2 mg, the
researchers reported reduction by more than 50% of base line
levels, in the amount of resting secretion, intraoral
accumulation, and pharyngeal-laryngeal pooling of saliva with
doses of 0.6 mg or greater.18
Table 1 shows a comparison of atropine sulfate with
Table 1. Comparison of atropine sulfate and
Active ingredient per tablet
Adult dose for dental application
Slowly, USP rating within 45 minutes
Adjunctive therapy in the treatment of peptic ulcer
ADA seal of acceptance
Safe for children
No. "Safety and effectiveness in children have not been
Glaucoma; synechiae; asthma.
Glaucoma; obstructive disease of the GI tract;
obstructive uropathy; intestinal atony of elderly or
debilitated patients; severe ulcerative colitis or toxic
megacolon complicating ulcerative colitis; unstable
cardiovascular adjustment in acute hemorrhage;
Cost (average wholesale price from 1996 RED BOOK)
$64.99/100 Tablets (15 mg)
Atropine is well absorbed from the GI tract and begins to
inhibit saliva flow within one hour. Peak inhibition occurs
approximately 2 hours after oral administration, and the effects
persist for up to four hours. The drug is metabolized by the
liver and excreted by the kidney.
Salivary secretions are generally inhibited by atropine at doses
lower than those required to affect other organs.19
Thus, it is possible to administer a low dose of medication
sufficient to achieve the desired oral effect while minimizing
systemic effects. Although individual tolerance varies greatly,
the effects highlighted in Table 2 may be encountered with the
Table 2. Dosage and related patient conditions.
Slight dryness of nose and mouth; bradycardia.
Greater dryness of nose and mouth with thirst; slowing,
then acceleration of heart; slight mydriasis
Very dry mouth; tachycardia with palpitations; mydriasis,
slight blurring of near vision; flushed, dry skin.
Increase in above symptoms plus disturbance of speech;
difficulty in swallowing; headache; hot, dry skin;
restlessness with asthenia.
10 mg and more:
Above symptoms to extreme degree plus ataxia, and
excitement, disorientation, hallucinations, delirium,
Note: Individual tolerance varies greatly.
Atropine has been reported to reduce the saliva mucus secretion
response to anesthesia and diminishes the amount of anesthesia
that must be used during operative procedures.21
It can help prevent laryngospasm because there is less tendency
for excessive saliva to irritate the larynx.22
It also eliminates any concern about potential backflow in
saliva evacuators or about hypersensitivity reactions to latex
used to construct rubber dams.23-25
The use of atropine during selected procedures has been reported
to enhance office productivity and to reduce chair time.26
Less preparation time is required because the patient comes to
the operatory with reduced salivary flow after having taken the
medication as directed. Fewer interruptions during dental
procedures are required to replace saturated cotton rolls,
reposition saliva evacuators, or redry tooth surfaces, and the
likelihood is that a single operator may perform the intended
procedure. Also, the need to repeat procedures to achieve
suitable technical results may be reduced. An example is bonding
during orthodontic bracket placement which can fail due to
saliva contamination of tooth surfaces.
Atropine sulfate tablets are approved, safe, and effective for
use in both adults and children. Dosing guidelines are available
for infant patients as small as 7 pounds.20
The conservative starting dose for patients weighing more than
65 pounds is one tablet. This dose may be exceeded in certain
cases, such as when treating large patients and heavy salivators
or when performing very sensitive procedures.
A practical dosing guideline to achieve suitable salivary
inhibition in adult dental patients is one tablet per 75 pounds
of body weight.27
This is consistent with a statement published by the American
Dental Association: "Most adults require a minimum of 0.6 mg and
as much as 1.0 mg of atropine before a real mouth drying effect
is noted clinically."21
A corresponding dosing guideline for small children is 0.01
mg/kg body weight, not to exceed 0.4 mg in a four to six hour
The tablets are tasteless and soluble to facilitate
administration to children.
Atropine sulfate is contraindicated in patients with glaucoma
and synechiae (adhesions between the iris and lens of the eye).
These two conditions are characterized by elevated intraocular
pressure due to impediments to the flow of aqueous humor. In
some patients, the impediment is caused by narrowing in the
angle between the pupil and lateral cornea. This narrowed angle
becomes further obstructed when the pupil dilates. Atropine
sulfate can cause dilation of the pupil; and consequently, it
must be avoided in susceptible patients.
Atropine sulfate is also contraindicated for patients with
asthma. In addition to inhibiting salivation, the medication can
also reduce bronchial secretions. Asthmatics rely on these
secretions to trap and expel inhaled allergens. Reducing the
efficacy of this cleansing system in such patients may cause
retention of these inhaled allergens and trigger bronchospasm.
Although not formally contraindicated, some practitioners advise
patients not to wear contact lenses or undertake heavy physical
activity within a few hours following the dental procedure
because of temporary reductions of tear and sweat secretions.12,26
The potential of atropine to reduce salivation and other
secretions may be increased if it is given with other drugs that
have anticholinergic action, including tricyclic
antidepressants, antipsychotics, some antihistamines, and
The safety and efficacy of atropine sulfate are well documented
by several decades of clinical experience. Table 3 reviews the
product features and patient benefits of atropine sulfate
tablets. Published reports from dental practitioners on the use
of this agent are positive, indicating that it increases patient
comfort during procedures and also increases the speed at which
various procedures can be completed successfully.26,28
Table 3. Product features and patient benefits of
atropine sulfate tablets.
Easy to swallow
No complaint of bad taste
Dissolves quickly in water
Easy to administer to children
Onset of effect
At recommended doses, will significantly reduce saliva
flow but not induce xerostomia
Patient does not feel uncomfortable
Possible adverse effects
Salivary glands are exquisitely sensitive to atropine
Can obtain desired oral effects with minimal exposure to
the rest of the body. Possible adverse effects at under
1 mg dose are dryness of mouth and nose, thirst,
bradycardia/tachycardia, and slight mydriasis.
Patient may drink water as directed by the dentist.
Short half-life and quick metabolism
The patient is under the dentist's observation while the
medication is at peak effect. By the time that the
patient is discharged from the office, medication is
likely past its peak effect and is dissipating.
After reviewing clinical literature and surveying expert
opinions, the American Dental Association Council for Scientific
Affairs awarded its Seal of Acceptance to atropine sulfate
tablets as an antisialagogue during dental procedures.
Control of saliva during many dental procedures is imperative
for achieving acceptable treatment results. Indicated to
temporarily reduce salivation in children and adults, atropine
sulfate tablets have been awarded the American Dental
Association Seal of Acceptance as an effective antisialagogue
for use during dental procedures. Used in conjunction with
cotton roll isolation, saliva ejectors, and rubber dams,
atropine tablets can improve patient comfort and enhance office
Craig R. Sherman, MD, is medical director, Hope Pharmaceuticals,
Scottsdale, AZ. Beryl R. Sherman, DDS, is a consultant to Hope
Pharmaceuticals, Dental Affairs, Lancaster, PA.
Address correspondence to: Craig Sherman, MD, Medical Director,
Hope Pharmaceuticals, 7626 E. Greenway Rd., Suite 101,
Scottsdale, AZ 85260.
Exercise No. 67
for Self Instruction Questions.
HW, Lund MR. Operative Dentistry. St. Louis, C.V. Mosby Co.;
E. Preparation of teeth for root canal treatment. In:
Endodontics. Bristol, England, Wright Publishing Co.;
Zachrisson BU. Bonding in orthodontics. In: Graber TM,
Vacarsdall RL Jr. ed. Orthodontics: Current Principles and
Techniques, ed 2. St Louis: C.V. Mosby Co. 1994:542-547.
DC. Dental cements. Dent Clin North Am 1983;27:778-786.
Jameson LM, Moser JB, Hesby RA. Adhesive properties of
several impression material systems: part II. J Prosthet
UME, Hagen K, Nielson DD. Periodontal repair in dogs: effect
of saliva contamination of the root surface. J Periodontol
TG. Inhibition of fibroblast attachment. J Clin Periodontol
Feigal RJ. Use of a bonding agent to reduce sealant
sensitivity to moisture contamination: an in vitro study.
Pediatr Dent 1992;14:41-46.
Silverston LM. The effect of salivary contamination in vitro
on etched human enamel. J Dent Res (Abstract) 1981;60:621.
FS. Endodontic therapy. St. Louis, C.V. Mosby Co. 1972:182.
N, Knight GT, Berry TG. Comparing two methods of moisture
control in bonding to enamel: a clinical study. Oper Dent
RN. Salivary control. J Clin Orthod 1981;15:562-564.
RA. Direct bonding metal brackets with the Concise-Enamel
Bond system. J Clin Orthod 1977;11:473-482.
prescribing information. Physician's desk reference, ed. 45.
Montvale, NJ: Medical Economics Data Production Co.;
Lonnerholm G., Widerlov E. Effect of intravenous atropine
and methylatropine on heart rate and secretion of saliva in
man. Eur J Clin Pharmacol 1975;8(3-4):233-240.
Drug Information, 1996, section 12:08:08/antimuscarinics/antispasmodics.
Bethesda, MD: American Society of Hospital Pharmacists;
RK. Comparative study of the effects of oral and i.m.
atropine and hyoscine in volunteers. Br J. Anaesth
J., Nadal J. Nonsurgical treatment of drooling in a patient
with closed head injury and severe dysarthria. Dysphagia
Medical Association. Anticholinergic antispasmodics:
anticholinergic compounds. AMA drug evaluations. Chicago:
Pharmaceuticals. Sal-Tropine Prescribing Information.
Dental Association. Accepted dental therapeutics. ed. 40.
Chicago: ADA; 1984.
MP, Green RA. Anaesthesia and sedation in dentistry.
Amsterdam, The Netherlands: Elsevier; 1983:198.
Campbell TL, Crawford JJ. Backflow in low-volume suction
lines: the impact of pressure changes. JADA
Meeroprol E. Latex allergy: update on clinical practice and
unresolved issues. J Wound Ostomy Continence Nursing
GS, Safadi TJ, Terezhalmy GT. Latex hypersensitivity: its
prevalence among dental professionals. JADA 1996;127:83-87.
MF. Atropine sulfate: a drying agent for sealant
application. J Southeast Soc Ped Dent 1997;3:20.
B. Personal Communication. 1997.
S. Atropine sulfate: an effective antisialogogue. J Clin