Dr Mandeep Kaur
Dry mouth (xerostomia) is the most common salivary complaint. Up to 30 percent of various populations self-report dry mouth or have proven low salivary flow rates (hyposalivation).
Oral complaints frequently include xerostomia, sore mouth or burning sensation, having to put a glass of water on the bedside table to drink at night; and difficulties in eating dry foods such as biscuits (the cracker sign), swallowing, speaking for long periods of time, and controlling dentures. Chronic complications of hyposalivation may include tooth demineralization and dental caries, gingival inflammation, and oral infections including fungal and bacterial infections.
How to diagnose
An examining dental mirror may often stick to the mucosa, there may be a lack of salivary pooling in the floor of the mouth, saliva flows poorly if at all from the ducts of the major glands on stimulation or palpation, and any saliva present tends to be viscous and appear frothy. There may also be food residues on teeth or mucosae and a characteristic tongue appearance, with a lobulated, usually red surface with partial or complete depapillation.
The normal salivary flow rate varies widely from person to person. The unstimulated whole saliva flow rate measurement is commonly used; this is a simple draining test for 5 minutes at rest. If the amount is less than or equal to 0.1 mL/ min, the patient has hyposalivation. Hyposalivation has a large impact on health-related quality of life, employment, and disability of patients. Any factor that increases illness severity or distress can result in an increase in dryness. Many patients who complain of a dry mouth lack objective evidence of hyposalivation, and in some this may reflect psychogenic conditions.
The main causes of genuine hyposalivation are drugs, cancer therapies, Sjögren syndrome, human immunodeficiency virus (HIV) disease, sarcoidosis, and dehydration. Many older patients complain of a dry mouth: indeed, in the older age groups, 16%-25% report xerostomia, but this is usually caused by drugs.
Clinical management is best based on the symptoms. Management is multidisciplinary and multimodal and essentially involves the use of salivary substitutes and/or salivary stimulants. It begins with simple measures, such as:
The patient sipping water or other fluids, protecting the lips with lip salve, and modifying eating (e.g., small bites of food, eaten slowly) and diet (creamy foods such as casseroles or soups; cool foods with a high liquid content such as melon or ice cream; and moistening foods with water, gravies, sauces, extra oil, dressings, sour cream, mayonnaise, or yoghurt).
Mouth-wetting (saliva substitutes) agents may help relieve xerostomia symptoms. Mouthwetting agents based on carboxymethylcellulose are particularly useful if they contain fluoride and are therefore protective against caries. Mouthwash and oral gel containing the antimicrobial proteins lactoperoxidase, lactoferrin, and lysozyme has been found to improve xerostomia. Salivary stimulation is readily and simply achieved using chewing gums and taste stimulation with citrus or other flavors, but sugar-free preparations should be chosen to avoid the risk of dental caries. Systemic medications (sialogogues) may also stimulate salivation, but can have adverse effects. Pilocarpine produces maximum saliva stimulation after 1 hour, and the effect continues for 2-3 hours and it increases salivation even after radiotherapy. Adverse effects may include sweating, flushing, urinary urgency, and gastrointestinal upset. It is contraindicated in narrow-angle glaucoma, acute iritis, or uncontrolled asthma. Cevimeline, with a similar pharmacological profile to that of pilocarpine and may also increase the secretion of some salivary digestive and/or defense factors.
Dental preventative care is thus indicated to avoid complications and professional dental attention is helpful in the diagnosis and management of dry mouth.
(The author is Assistant Professor Deptt of Oral Pathology & Microbiology Indira Gandhi Govt Dental College, Jammu)
Dr Mandeep Kaur