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XEROSTOMIA

Maria Gawrioek

Xerostomia

Xerostomia (dry mouth)subjective complaint of dry mouth that mayresult from a decrease in the production ofsaliva.

Salivary Gland Dysfunction and

Xerostomia

Clinical Appearance:

Oral mucosa appears dry, pale, or atrophic.

Tongue may be devoid of papillae withfissured and inflamed appearance.

New and recurrent dental caries.

Difficulty with chewing, swallowing, and

tasting may occur. Fungal infections are common.

Xerostomia

Xerostomia Saliva

Dry mouth (xerostomia) occurs when there is achange in the quality or a decrease in thequantity of saliva.

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Importance of Saliva in oral health:

It keeps the teeth healthy by providing alubricant, calcium, and a buffer.

It also helps to maintain the health of oraltissues (mucosa), and throat.

It also plays a role in the control of bacteria inthe mouth.

It helps to cleanse the mouth of food anddebris.

Importance of Saliva in oral health:

It provides minerals such as calcium, fluoride,and phosphorus.

It helps in swallowing and digesting food.

Lack of saliva will make the mouth more proneto disease and infection.

Lead to a burning feeling.

Pathophysiology

Daily salivary output is estimated to beapproximately 1 liter/day

Flow rates can fluctuate by as much as 50%with diurnal rhythms.

Secretion of saliva

Normal secretion of non stimulated saliva is 0.3-

0.4 ml/min.

Secretion less than 0.1 ml/min = xerostomia

Normal secretion of stimulated saliva is

1-2 ml/min

Secretion less than 0.2-0.5 ml/min = xerostomia

Etiology

Medications (especially selective serotoninreuptake inhibitors); in the geriatric population,drug induced xerostomia has been reported tocontribute to difficulty with chewing, swallowingand denture retention. This may lead toavoidance of eating certain food.

Ionizing radiation can injure the major andminor salivary glands which may lead to atrophyof the secretory components and results in

varying degrees of temporary or permanentxerostomia.

Etiology

Toxic substances in chemotherapeutic agents.

Xerostomia has been reported in 45-60% of patients

who developed chronic graft-vs.-host disease afterundergoing allogenic bone marrow transplantation.Loss of saliva and a number of immunologicalabnormalities also have been implicated as possible

complications of silicone breast implants.

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Oral Dryness in the Elderly

0

10

20

30

40

50

60

70

80

90

Normal Radiotx Sjogren Drugs

Subjective sensation of oral dryness in the

elderly

%P

opulatio

n

Diagnosis

It has been estimated that a 50% reduction insalivary secretion needs to occur before the

xerostomia becomes apparent.

An affirmative response to at least one of thefive following questions about symptoms hasbeen shown to correlate with a decrease in

salivary flow:

Questions:

1. Does your mouth usually feel dry?

2. Does your mouth feel dry when eating a meal?

3. Do you have difficulty swallowing dry food?

4. Do you sip liquids to aid in swallowing dry food?

5. Is the amount of saliva in your mouth too little mostof the time, or dont you notice it?

Warning Signs

Dry, burning mouth and throat

Dry, cracking lips, especially in the corners. The cracks

may be tender and/or bleed

Problems with denture wearing

Problems with eating and swallowing food

Difficulty with speech due to mouth soreness

Increased incidence of caries and periodontal disease

Types of Xerostomia

True xerostomia (primary)- dysfunction of

salivary glands due to local or systemic disease

Pseudo xerostomia (secondary)- no changes ofsalivary glands; main reasons are changes in

emotional state, psychotic states, and drugs

Medications Causing Xerostomia

Anticholingergic

Antidepressant

Antihistamine

Bronchodilator

Diuretic

Muscle Relaxant

Sedative

Anti-inflammatory

Antiacne Analgesic

Anorexiant

Antipsychotic

Decongestant

Anticonvulsant

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True Xerostomia

TYPE I- xerostomia, sometimes additionally withburning in mouth and throat. Without other symptoms

in oral cavity. Depression

Diseases with higher fever or other reasons causingdehydration.

Salivary gland diseases (inflammation, Mikuliczs disease,atrophy after treatment with ionizing radiation)

Arterial hypertension, arteriosclerosis

Congenital lack of salivary glands

True Xerostomia

TYPE II- xerostomia with atrophy inflammation ofmouth mucosa

Atrophic inflammation of tongue Angular cheilitis

Exfoliative cheilitis

Burning of mouth and tongue

Difficult in swallowing

Gastritis

Anemia

Caries floridarapid loss of teeth

Xerostomia

It affects 17-29% of sample populations based

on self-reports or measurements of salivary flowrates.

More prevalent in women.

Can cause significant morbidity and a reductionin a patients perception of quality of life.

Grading of Xerostomia

Grading based on subjective feeling of drymouth only, is not sufficient enough tointroduce proper treatment, because it may notcorrelate with objective function of salivaryglands.

Flow rate of Saliva

Measurement of flow rate of saliva allows

monitoring of salivary glands and verify orchange therapy.

It is especially important in case of patientsundergoing radiotherapy of neoplasms of head

and neck and chemotherapy, when function ofsalivary glands changes during therapy.

Flow rate assessment

Collect non stimulated saliva during 5 minutes.Quantitative assessment of saliva production iscalculated as volume of saliva produced onaverage in one minute.

Collect stimulated saliva (chewing a piece ofparaffin) during 5 minutes.

Collect saliva for 2 minutes after 20 seconds ofactivation with 4% citronic acid dropped onboth sides of tongue.

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Flow rate assessment

When unstimulated salivary flow is less than0.12 to 0.16 ml/minute, a diagnosis of

hypofunction is established.

Up till now there is no standard concerningsalivary gland function tests. Therefore results

cannot be compared between laboratories.

Symptoms

Dry mouth

Frequent need of sipping water during eating orspeaking

Difficulty in chewing and swallowing

Burning of tongue and/or lips

Distaste (most often salty and bitter taste)

Acute caries in atypical localization

Symptoms

Decreased tolerance of prosthetics

Dryness and irritation of throat

Dryness of eyes

Blurred vision

Dryness of nose

Dryness of mouth

Unpleasant breath

More common secondary bacterial and fungalinfections

Higher risk of teeth demineralisation, crown androot caries, enamel erosions

Inflammation of mucosa

Dryness of mouth

Food sticking to teeth

Difficulty in speaking

Increase in saliva viscosity

Changes in parodontium: gingivitis(accumulation of dental plaque)

Decrease in quality of life

Management

The general approach to treating patients withhyposalivation and xerostomia is directed atpalliative treatment for the relief of symptomsand prevention of oral complications

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Symptomatic Treatment

Sip water frequently all day long

Let ice melt in the mouth

Restrict caffeine intake

Avoid mouth rinses containing alcohol

Humidify sleeping area

Coat lips with lubricant.

Coat lips with a petroleum jelly like Vaseline,Blistex, or lanolin.

Hygiene

Maintain good oral hygiene. Floss daily.

Brush at least twice a day.

Use special toothpaste:

- with fluoride and alcohol free (e.g. Biotene toothpaste)

- without detergents and sodium-laurylosulphate

- often the same as for children

Use chlorhexidin

Fluoride prophylaxis

Advice for patients

Use topical fluoride.

Apply moisturizing gels inside of the mouth (e.g.Biotene oral balance).

Rinse with a recommended mouth rinse (e.g.Biotene mouth wash).

Use an artificial saliva to moisten the mouth.

Diet

Restrict consumption of monosaccharides or

substitute with aspartame, saccharine, acesulfam,sorbitol, xylitol

Sugar free chewing gums

Avoid eating foods that are dry, sour, spicy and

increasing thirst

Diet

No alcohol

No cigarettes

Frequent drinking of water and other neutralnon caffeine drinks

Chewing lemon/orange peel

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Saliva Stimulants

The use of sugar free gum, lemon drops ormints are conservative methods to temporarilystimulate salivary flow in patients withmedication xerostomia or with salivary glanddysfunction.

Treatment

Treatment of primary disease

Verifying doses of drugs

Swabbing with vitamin A+D solution

Vitamin A, B, E

Vitamin C

Consult with physician todecrease drug dose, alter drugdosages, or substitute one

xerostomic medication for asimilar-acting drug with fewersalivary side effects.

Treatment

2% solution of potassium iodide (twice a day 1teaspoon per os)

Pilocarpine (3x/day 5 drops per os)

Rinse with 1% Pilocarpine (15-20 drops in 1glass of water)

Pilocarpine HCl (Salagen) (1-2 tablets tid1/2hour prior to meals. Some authors recommend

using 1 tablet of pilocarpine 4-5 times daily)

Pilocarpin HCl

May need 2-3 months to determineeffectiveness.

Side effects include: sweating and diarrhea.Avoid use in patients with narrow angle

glaucoma, severe asthma and pulmonarydiseases.

Treatment

Physostygmine

It inhibits secretion of acetylocholinesterase,prolonging action of acetylocholine causingproduction of watery saliva.

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Treatment

Artificial saliva:

- Saliram lemon, Moi-Stir artificial Saliva,

Salivart, Synthetic Saliva, Glandosane, Artisial,Saliment, Biotene

Moisturising agent Oralbalance

Saliva substitutes (with mucine orcarboxymetylocellulose)

ex. Carboxymetylocelulosi 0,5% sol.

D.S. for swabbing

Commercial Salivary Substitute

Commercial oral moisturizing gels (OTC)includes:

OralBalance

XERO-Lube

Salivart

Moi-Stir Orex

Optimoist

Oral Balance Ingredients

Polyglycerylmethacrylate (moisturizing agent)

Lactoperoxidase (antibacterial)

Glucose Oxidase (antibacterial)

Lysozyme (antibacterial)

Treatment

Saliva Stymulator (Biosonics Sal SalivarorSystem) Electronic stimulator- stimulates receptors of touch,

taste and muscle mechanoreceptors.

It stimulates for 3 minutes, than turns offautomatically and emits a signal. Stimulation dependson individual toleration.

Patients are taught how to put electrodes on thetongue in 3 minutes cycle.

Results positive in 50% cases.

Conditions

Sjorgens syndrome

Reumatoidal arthritis

Lupus erythromatosus

Crohns disease

Primary Biliary Cirrhosis

Graft vs host reaction

Bone marrow transplantation

Sarkoidosis

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Other Conditions

Diabetes type 1 or 2

Pancreas infections

Hypertension Hyperthyroidism

Chemotherapy

HIV

AIDS

Vasculitis

Chronic Active Hepatitis

Renal Dialysis

Stress and Depression