|Year : 2014 | Volume
| Issue : 2 | Page : 190-194
Xerostomia: Few dry facts about dry mouth
Prasanna Kumar J Rao, Laxmikanth Chatra, Prashanth Shenai, KM Veena, Rachana V Prabhu, Tashika Kushraj, Prathima Shetty, Shaul Hameed
Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka, India
|Date of Web Publication||11-Nov-2014|
Prasanna Kumar J Rao
Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Nithyananda Nagar, PO - Deralakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Xerostomia is the subjective feeling of oral dryness, which is often associated with hypofunction of the salivary gland. Xerostomia can also have a major impact on a patient's oral health and quality of life. Patients with xerostomia complaints of problems with mastication, phonetics, deglutition and wearing dentures. Treatment of this condition always depends on the cause. Oral physicians should be able to diagnose this condition and able to give proper treatment to provide comfort to their patients. This article reviews the causes of xerostomia and its management.
Keywords: Drymouth, saliva, salivary flow, xerostomia
|How to cite this article:|
Rao PJ, Chatra L, Shenai P, Veena K M, Prabhu RV, Kushraj T, Shetty P, Hameed S. Xerostomia: Few dry facts about dry mouth
. Arch Med Health Sci 2014;2:190-4
|How to cite this URL:|
Rao PJ, Chatra L, Shenai P, Veena K M, Prabhu RV, Kushraj T, Shetty P, Hameed S. Xerostomia: Few dry facts about dry mouth
. Arch Med Health Sci [serial online] 2014 [cited 2020 Feb 19];2:190-4. Available from: http://www.amhsjournal.org/text.asp?2014/2/2/190/144335
| Introduction|| |
Saliva plays an important role in maintaining good oral and general health. People become aware of its importance only when the salivary flow reduces. It causes reduction of person's quality of life.  Saliva is a complex fluid, which is composed of 99% of water and only 1% of non organic and organic substances  [Table 1]. These constituents are from within the gland and transported from the blood.  The major role of these components present in the saliva are to provide prophylactic, therapeutic and diagnostic properties to saliva. The compounds which are present in the saliva are also present in the blood.  A large number of analytes in saliva are discovered and some of them are used as biomarkers different diseases such as periodontal diseases, oral cancer, breast cancer, autoimmune diseases, HIV, cardiovascular disease, diabetes mellitus, viral and bacterial disease. ,, Because of molecular diagnostics and nanotechnology, saliva is becoming valuable source of diagnostic information. 
In the oral cavity saliva serves many functions  [Table 2]. It helps in normal functioning of oral cavity. It is also very important for better retention of dentures in the oral cavity. 
| Salivary Flow Assessment|| |
Saliva secreted in the oral cavity by three pairs of major salivary glands and hundreds of minor salivary glands which are distributed throughout the oral cavity [Table 3].  Flow rates of saliva gives information about function of salivary glands. There are different methods used to evaluate the salivary gland secretion and drymouth. These methods includes self-reported questionnaires, visual analog scales (VAS), simple functional measures by using mouth mirrors, by asking the patient to chew and swallow dried biscuits with water, sialography, sialoscintigraphy, sialoultrasonography, sialometry of the minor salivary glands and biopsy.  Other methods are by measuring volume of residual saliva on mucosal surfaces using filter paper and micromoisture meter and calculating thickness, and using mucosal wetness devices. 
Among these methods sialometry is the most objective method to assess salivary function. This method is used to determine the quantity of both resting and stimulated whole saliva.  In a normal individuals daily secretion of saliva is approximately 1.5 L per day (0.5-1mL/min). This normal flow rate also varies due to diurinal variation, hydration, food intake and other factors. Unstimulated wholesaliva flow rate less than 0.1 mL/min and stimulated salivary flow rate less than 0.5 mL/min, respectively, is an indication for hyposecretion of saliva or hyperfunction of salivary glands. Functioning of parotid saliva can be done by collecting exclusive parotid saliva using carlson crettinden cups. 
Hypofunction and hyposalivation is a subjective complaint of oral dryness due to various causes, the condition termed as xerostomia. This term was derived from Greek word 'xeros' (dry) and 'stoma' (mouth).  It is the most common complaint why a patient visits a dental specialist. This condition adversely affects an oral function which leads to oral sequelae-like mucosal dryness, difficulty in speech, chewing and swallowing, oral burning sensation, increased fungal infection, demineralization of teeth, halitosis and difficulty in wearing dentures. 
The following questions should be asked to detect drymouth. 
- Do you sip liquids to aid in swallowing dry foods ?
- Does your mouth feels dry when eating a meal ?
- Do you have difficulties swallowing any foods ?
- Does the amount of saliva in your mouth seem to be too little ?
- Does your nose or throat feel dry and tickly ?
- Do you have a dry cough, hoarseness, nose bleeds or decreased sense of taste or smell ?
Patients who respond positive to these questions with salivary flow rate less than 0.1 mL/ min are diagnosed as salivary hypofunction.
| Causes of Xerostomia|| |
The prevalence of xerostomia in general population is varying. But prevalence with Sjogren's syndrome and patients receiving radiotherapy for head and neck cancer was 100%.  The studies shows that prevalence increases with age and it is more in postmenopausal women (10.3-33.7%) compared to men (9.7-25.8%).  It is important to note that multidimentional factors are associated with xerostomia. Emotional disorders, such as a panic attack caused by severe anxiety, may cause dry mouth due to the stress or "flight or fight" response, which reduces saliva production in the mouth. In such condition patient complains of dryness of mouth but on sialometry there is no abnormality detected. It is also a problem in a young patients particularly those who taking antidepressant drugs [Figure 1]. 
This condition has variety of causes, which is divided in to two main categories:  [Table 4]
- Direct causes - Primary causes or direct causes are the conditions which directly affect the salivary glands and decrease the salivary flow rate.  The most common autoimmune disease which is associated with xerostomia is Sjogrens syndrome [SS]. It is charecterized by inflammation of exocrine glands. The primary SS or sicca syndrome shows only eye and oral symptoms. In SS lymphocytic infiltration destroys the secretory acini of major and minor salivary glands and causes hyposalivation. 
- Indirect causes - Secondary causes or indirect causes are conditions in which Xerostomia is the side effect. Irradiation and cytotoxic drugs causes sialadenitis which causes irreversible damage to acinar cells.  It is also a side effect of variety of other autoimmune disorders.
Among the most commonly prescribed drugs around 80% of the drugs causes xerostomia.  Around 42 categories and 56 sub-categories of drugs shows adverse effect of xerostomia  [Table 5].
| Dental Implications|| |
Xerostomia affects the quality of life of patients. These patients may be asymptomatic or frequently complain of dry mouth which develops many complications. Patients with dry mouth experience various oral symptoms. There are many consequences and complications of xerostomia  [Table 6].
- Oral mucosa - It is very sensitive, prone to injuries and damage, burning sensation, altered taste and halitosis. In case of radiotherapy oral mucosa becomes dry and large ulcers appear in the path of radiation. 
- Dentures - Lack of lubrication due to drymouth causes traumatic mucosal ulcers, increased susceptibility of fungal infections causes difficulties in wearing dentures. Using flexible dentures in radiation induced patients with minimal tissue damage during and after denture construction procedures. 
- Caries - Dry mouth increase the risk of generalized caries, enamel erosion and periodontal diseases. It decreases the oral pH which causes increased plaque accumulation and dental caries. Radiation-induced caries is common in patients who is undergoing head and neck radiotherapy. 
- Fungal infection - In moderate to severe case of salivary gland hypofunction oral candidiasis and salivary gland enlargement due to sialadenitis is seen. Risk of fungal infection increases in patients who wear dentures, smoking and alcohol habits and diabetics. 
| Management|| |
Management of xerostomia is based upon the cause and severity of salivary gland damage. So treatment comprises of etiologic, stimulative, symptomatic or palliative approach. Patients with dry mouth should increase intake of water. They should be advised to place ice chips in the mouth or sip water every 5-10 minutes to provide moisture in the mouth.  Patients with remaining salivary function, acidic taste provided by sugar-free chewing gums, solid food or fruits can effectively stimulate salivary flow. In such patients we should advise to reduce sweet foods to prevent dental caries and increase water intake. Patients with drymouth should avoid spicy foods, dry foods and hard crunchy foods. They should dunk them in liquids. Advice them to eat such foods with small bites and eat slowly. Advice to eat soft creamy foods or cool foods with high liquid content like watermelon, grapes, and icecreams. Water or non-alcoholic drinks with meals will also helps. Lips can be protected by applying lip salve or petroleum jelly. 
Patients with drymouth are at high risk for dental caries and halitosis. An extra effort is needed to protect against decalcification of teeth, dental decay and halitosis by reducing sugar intake, avoiding sticky foods such as toffee, keeping mouth very clean by brushing twice daily and flossing, using fluoride tooth paste, using fluoride jells or mouth washes daily. They should go for regular dental checkups. Thorough dental checkup with bitewing radiographs are necessary to detect any new carious lesions. 
There is high risk of periodontal diseases in drymouth patients. Proper oral hygienemaintenance and use of electric tooth brush helps to effectively remove plaque. These patients areadvised to receive periodontal prophylaxis every 3 months to reduce periodontal disease. Use of antibacterial mouth washes may reduce gingivitis. 
Oral candidiasis is commonly seen in patients with xerostomia. These patients should be prescribed topical antifungal agents. When topical medication is ineffective, systemic antifungal medications are recommended.  Non-selective muscarinic receptor agonists such as pilocarpine or civemiline will increase salivary function in patients with xerostomia. Oral lubricants like vitamin E or oral balance also helpful in case of drymucosa and cracked lips. Tooth-whitening products should be avoided because they irritate the oral tissues [Table 7]. 
Few studies also proved that use of acupuncture in the management of xerostomia is effective in increasing the saliva flow rate. Electrical stimulation therapy also used in salivary hypofunction.  In case of drugs which causexerostomia, dentist should consult the patient's physician and request him to prescribe an alternative drug which employs other mode of action. Advice the patient to avoid taking medications before bedtime because salivary flow rate is low during sleep. 
| Summary|| |
Xerostomia is a subjective perception of oral dryness. There may be various degree of salivary hypofunction depending upon the causes. Early diagnosis and treatment can slow progression of dry mouth and improve the quality of life of the patient. Routine follow-up care between the physician and dentist is necessary to prevent xerostomia.
| References|| |
|1.||Scully C, Felix DH. Oral medicine - Update for the dental practitioner: Dry mouth and disorders of salivation. Br Dent J 2005;199:423-7. |
|2.||Mravak-Stipetic M. Xerostomia - Diagnosis and treatment. Medical Sciences 2012;38:69-91. |
|3.||Guggenheimer J, Moore PA. Xerostomia: Etiology, recognition and treatment. J Am Dent Assoc 2003;134:61-9. |
|4.||Lee YH, Wong DT. Saliva: An emerging biofluid for early detection of diseases. Am J Dent 2009;22:241-8. |
|5.||Bigler LR, Streckfus CF, Dubinsky WP. Salivary biomarkers for the detection of malignant tumors that are remote from the oral cavity. Clin Lab Med 2009;29:71-85. |
|6.||Lazarevic V, Whiteson K, Gaïa N, Gizard Y, Hernandez D, Farinelli L, et al. Analysis of the salivary microbiome using culture-independent techniques. J Clin Bioinforma 2012;2:4. |
|7.||Rao PV, Reddy AP, Lu X, Dasari S, Krishnaprasad A, Biggs E, et al. Proteomic identification of salivary biomarkers of type-2 diabetes. J Proteome Res 2009;8:239-45. |
|8.||Spielmann N, Wong DT. Saliva: Diagnostics and therapeutic perspectives. Oral Dis 2011;17:345-54. |
|9.||Turner M, Jahangiri L, Ship JA. Hyposalivation, xerostomia and the complet denture: A systematic review. J Am Dent Assoc 2008;139:146-50. |
|10.||In: Sreebny LM, Vissink A, editors. Dry Mouth, the Malevolent Symptom: A Clinical Guide. Singapore: Wiley-Blackwell; 1 st Ed 2010. p. 268. |
|11.||Grisius MM, Fox PC. Salivary gland diseases. In: Greenberg MS, Glick M, editors. Burket's Oral medicine. Diagnosis and treatment.10 th ed Hamilton, Ontario: BC Decker; 2003. |
|12.||Takahashi F, Koji T, Morita O. Oral dryness examinations: Use of an oral moisture checking device and a modified cotton method. Prosthodont Res Pract 2005;5:26-30. |
|13.||Wiener RC, Wu B, Crout R, Wiener M, Plassman B, Kao E, et al. Hyposalivation and xerostomia in dentate older adults. J Am Dent Assoc 2010;141:279-84. |
|14.||Ghezzi EM, Lange LA, Ship JA. Determination of variation of stimulated salivary flow rates. J Dent Res 2000;79:1874-8. |
|15.||Thomson WM. Measuring change in dry-mouth symptoms over time using the Xerostomia Inventory. Gerodontology 2007;24:30-5. |
|16.||Singh T. Xerostomia: Etiology, diagnosis and management. Dent today. 2012;31:82-83. |
|17.||Ship JA, Pillemer SR, Baum BJ. Xerostomia and the geriatric patient. J Am Geriatr Soc 2002;50:535-43. |
|18.||Närhi TO. Prevalence of subjective feelings of dry mouth in the elderly. J Dent Res 1994;73:20-5. |
|19.||Murray Thomson W, Poulton R, Mark Broadbent J, Al-Kubaisy S. Xerostomia and medications among 32-years-olds. Acta Odontol Scand 2006;64:249-54. |
|20.||Thomas BL, Brown JE, McGurk M. Salivary gland disease. Front Oral Biol 2010;14:129-46. |
|21.||Pijpe J, Kalk WW, Bootsma H, Spijkervet FK, Kallenberg CG, Vissink A. Progression of salivary gland dysfunction in patients with Sjögren's syndrome. Ann Rheum Dis 2007;66:107-12. |
|22.||Navazesh M, Kumar SK. University of Southern California School of Dentistry. Measuring salivary flow: Challenges and opportunities. J Am Dent Assoc 2008;139 Suppl:35-40S. |
|23.||Gupta A, Epstein JB, Sroussi H. Hyposalivation in elderly patients. J Can Dent Assoc 2006;72:841-6. |
|24.||Fox PC, Bowman SJ, Segal B, Vivino FB, Murukutla N, Choueiri K, et al. Oral involvement in primary Sjogren syndrome. J Am Dent Assoc 2008;139:1592-601. |
|25.||Dabas N, Phukela SS, Yadav H. The split denture: Managing xerostomia in denture patients: A case report. J Indian Prosthodont Soc 2011;11:67-70. |
|26.||Porter SR, Scully C, Hegarty AM. An update of the etiology and management of xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:28-46. |
|27.||Brennan MT, Fox PC. Xerostomia: Diagnosis, management and sjogren's syndrome. In: Brennan MT, Fox PC, editors. Clinicians Guide to Salivary Gland and Chemosensory Disorders. Edmonds: American Academy of Oral Medicine; 1 st ed 2009. p. 5-25. |
|28.||Braga FP, Lemos Junior CA, Alves FA, Migliari DA. Acupuncture for the prevention of radiation-induced xerostomia in patients with head and neck cancer. Braz Oral Res 2011;25:180-5. |
|29.||Diaz-Arnold AM, Marek CA. The impact of saliva on patient care: A literature review. J Prosthet Dent 2002;88:337-43. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]