Journal of Dental Sciences & Oral Rehabilitation

www.rmc_bareilly.com REVIEW ARTICLE

28
ABSTRACT
Xerostomia is a condition of dry mouth that is experienced by many patients and is frequently
encountered in medical practice. It often develops when the amount of saliva that moistens the oral
mucous membrane is reduced. A number of commonly prescribed drugs with a variety of
pharmacological activities have been found to cause xerostomia as a side effect. Additionally,
xerostomia often is associated with Sjgren's syndrome and complication of radiation therapy.
Xerostomia is related with difficulties in chewing, swallowing, tasting or speaking. Xerostomia can
predispose to an increased risk of developing dental caries. It can also cause oral discomfort for
denture wearers. Management strategy for this condition should include caries prevention and
elimination of drugs having anticholinergic effects. Treatment is based primarily on replacement
therapies and gustatory, masticatory, and pharmacological stimulants. Healthcare professionals can
play a vital role in identifying patients at risk for developing xerostomia, and should provide appropriate
preventative and therapeutic measures that will help to preserve a person's health, function, and quality
of life. The purpose of this review is to discuss the common causes, clinical manifestations,
complications and treatment modalities available, which will assist the clinicians to manage the
xerostomic patients.
KEY WORDS: Xerostomia; Sjgren's syndrome; Oral mucous membrane.
XEROSTOMIA- A REVIEW AND UPDATE
AUTHOR : S
Dr. Gaurav Sapra
Senior Lecturer
Department of Oral Pathology
and Microbiology,
Institute of Dental Sciences, Bareilly (U.P.)
Dr. P.K.Singh
Assistant Professor
Department of Anatomy
R.M.C.H., Bareilly (U.P.)
Dr. Rahul Agarwal
Assistant Professor
Faculty of Dental Sciences
IMS, BHU, Varanasi (U.P.)-INDIA
Dr. K. T. Chandrashekar
Professor & Head,
Deptt. of Periodontology & Implantology
Hitakarini Dental College & Hospital,
Jabalpur (MP)- INDIA.
INTRODUCTION:
Saliva is a complex fluid produced by the
salivary glands. It forms a film of fluid coating the
teeth and mucosa thereby creating and regulating a
healthy environment in the oral cavity.[1]
Saliva is derived predominantly from three
paired major salivary glands, i.e. the parotid,
submandibular and sublingual glands (together
accounting for about 90% of the fluid production) as
well as from the minor salivary glands in the oral
mucosa. Whole saliva also contains gingival
crevicular fluid, microorganisms from dental plaque
and food debris. In healthy individuals the daily
production and swallowing of saliva normally ranges
from 0.5 to 1.5 Liters and it is composed of more than
99% water and less than 1% solids, mostly proteins
and salts.[2] Saliva is thought to be secreted by a two-
stage mechanism. Acinar cells produce an osmotic
gradient that is mediated by a co-transporter loop in
the basolateral membrane. This osmotic gradient
results in the production of salivary fluid.[3, 4]
Reduced saliva, either qualitatively or
quantitatively, may negatively impact on oral health.
Research indicates that there is a loss of salivary
parenchymal acinar cells which occurs in ageing.[5]
These effects are often unrecognized as the parotid
gland is capable of maintaining function without
obvious changes in amount, composition or
variability.[6]
Xerostomia is a condition associated with both a
decrease in the amount of saliva produced and an
alteration in its chemical composition, therefore
causing feeling of dry mouth. This can have a
deleterious effect on many aspects of oral function and
general well being. It can cause a significant decline in
quality of life by decreasing taste sensation and
impairing chewing ability. Furthermore, it may alter
regular eating patterns, reducing the pleasure of eating
due to impaired or diminished taste sensation. Patients
with xerostomia often report an avoidance of some
foods, such as dry foods (bread) and sticky foods, due
to the inability to chew or swallow effectively. Also,
xerostomia may impair a patient's ability to speak,
cause cracks and fissures in the oral mucosa and
halitosis. It can cause denture wearing to be very
uncomfortable, exacerbating chewing difficulties.
Xerostomia can affect numerous aspects of oral
function, contributing to pain, caries and oral
infections.[7]
EPIDEMIOLOGY
Xerostomia may develop in any person of any
age, But it is frequently described as a symptom of
middle-aged and elderly individuals.
In a questionnaire based study on 710 American adults
ranging in age from 19 to 88 years, it was observed that
24% of females and 18% of males suffered from
xerostomia. It was also found that xerostomia was
associated with the use of medications and in males,
cigarette smoking was the main cause associated. The
hyposalivatory side-effects like difficulty in
consuming dry foods, cracked lips, dry eyes, difficulty
in swallowing were also reported.[8] It has also been
reported that the prevalence of dry mouth symptoms
increased with age, was more common in women than
men and was greater in whites than blacks.[9]
The prevalence of perceived dry mouth among a
group of elderly people in Japan was also investigated.
It was found that 37.8% reported oral dryness on
waking, yet only 9.1% of individuals noticed a
subjective feeling of dry mouth during eating.[10] The
relationship between complaints of xerostomia and
food avoidance in geriatric patients was analysed in a
the soft and hard tissues.[35]
It may be difficult to measure salivary flow rates in common
practice. Therefore, following four methods as the clinical measures of
salivary flow rates have been suggested. They are dryness of the buccal
mucosa, absence of saliva expressible from the ducts, the total number of
decayed, missing and filled teeth, and dryness of the lips.[35]
CLINICAL MANIFESTATIONS
Patient with xerostomia usually complaints of a dry mouth, burning
sensation of oral mucosa and a sensation of a loss of or altered taste.
Another manifestation may be an increased need to sip or drink water
when swallowing, difficulty with swallowing dry foods or an increasing
aversion to dry foods.[11] Patients who develop Sjgren's syndrome
secondary to a connective tissue disease also may complain of having dry
eyes, and progressive parotid gland enlargement may become evident.
These initial manifestations may precede clinically apparent alterations
of the oral mucosa or any measurable reduction in salivary gland
function.
As the xerostomia progresses, inspection of the oral cavity may
disclose an erythematous pebbled, cobblestoned or fissured tongue and
atrophy of the filiform papillae. The oral tissues may be erythematous
and appear parched. Palpation of the oral mucosa may result in the
finger's adhering to the mucosal surfaces instead of readily sliding over
the tissues. Application of a dry cotton swab at the parotid and sub-
mandibular duct orifices followed by external palpation of the glands
may reveal delayed or inapparent salivary flow from the ducts. Halitosis
is a common problem and the dryness of the mouth and lips can cause
discomfort ranging from mild irritation to a severe burning sensation.
.[36]
Desiccated oral mucosal tissues are more susceptible to ulcerations
and traumatic lesions. Soft tissue management includes maintaining
mucosal integrity to avoid local or systemic infections from oral
microflora. Dry mouth induced oral lesions are susceptible to developing
secondary infections by microbial flora that normally inhabit the oral
cavity as well as by exogenous organisms. Patients with significantly
decreased salivary output due to prolonged xerostomia have an increased
risk of developing dental caries. .[37] This is a result of the decrease in pH
of saliva and the colonization of cariogenic bacteria, namely
Streptococcus mutans and Lactobacillus species. Reduction of saliva
increases the risk of developing candidiasis also.[38]
MANAGEMENT
The general approach to treat patients with xerostomia is primarily
palliative for the relief of symptoms and prevention of oral complications.
Dental Caries Prevention
With reduction in saliva, the patients are more prone to dental caries and
therefore diligent oral hygiene and regular dental care is essential. A
number of therapeutic interventions are available for the control and
prevention of dental caries. These primarily consist of rigorous attention
to personal oral hygiene, strict adherence to a non-cariogenic diet,
placement of sealants and the application of topical fluorides. The latter
may be useful if an increased incidence of coronal caries, root caries or
both becomes apparent, even when fluoridated community water is
available. This strategy may be effective for both prevention of caries and
possible reversal of decalcification. Supplements that contain sodium
fluoride, acidulated phosphate fluoride or sodium mono-
fluorophosphate are available for professional application as well as for
home use.[39] Use of fluoride varnishes can provide prolonged exposure
to fluoride.[40]
Saliva Substitutes
Artificial saliva substitutes have been shown to give relief by rehydrating
the oral mucosa.[41] Since saliva is a complex secretion with a variety of
functions, it is difficult to mimic through artificial methods.
Milk also contains many chemical and physical properties suitable
as a saliva substitute. It acts by moisturizing and lubricating dehydrated
tissues, buffering oral acids, decreasing the risk of enamel
demineralisation, and it also contributes to remineralization due to its
calcium and phosphate content.[42]
Artificial saliva preparations can be categorized based on their
contents: glycerine and lemon or carboxy-methyl-cellulose and mucin.
They include remineralising contents such as calcium, phosphate,
fluoride and sugar alcohols (e.g. sorbitol), which have a low cariogenic
potential.[43]They are important for lubrication of the mucosa and throat
and help to clean teeth from bacteria and debris. Saliva substitutes are
available as lozenges, rinses, sprays, swab sticks and as reservoirs in
dentures.[44]
Treatment with Optimoist (liquid spray saliva substitute), Saliva
Orthana (mucin-based artifcial saliva), Freedent (low-tack, sugar-free
chewing gum) and Xialine (xanthan gum-based saliva substitute) have
also been suggested.[45]
Journal of Dental Sciences & Oral Rehabilitation 30
Cholinergic Agonists- Salivary Secretion Stimulants
Treating xerostomia with medications that enhance salivation is another
therapeutic option, particularly in the relatively healthy person.
Secretogogues such as pilocarpine can increase secretions and diminish
xerostomic complaints in patients with sufficiently remaining exocrine
tissue. Pilocarpine is typically given in a dosage of 5 mg orally three
times a day and before bedtime. When taken 30 min before mealtime,
patients may benefit from the increased salivation in eating their meal.
The total daily dose should not exceed 30 mg. Adverse effects include
increased perspiration, greater bowel and bladder motility, and feeling
hot and flushed. Patients with a history of bronchospasm, severe chronic
obstructive pulmonary disease, congestive heart disease, and angle
closure glaucoma should not take pilocarpine.[45]
A new secretogogue, cevimeline, has recently been approved by the
United States Food and Drug Administration for the treatment of dry
mouth in Sjgren's syndrome in a dosage of 30 mg orally three times
daily. Like pilocarpine, it is a muscarinic agonist that increases
production of saliva. Pilocarpine is a non-selective muscarinic agonist,
whereas cevimeline reportedly has a higher affinity for M1 and M3
muscarinic receptor subtypes. Bethanechol, another cholinergic agonist,
has been used (25 mg tid) to stimulate saliva in post head and neck
radiotherapy patients, with few reported significant side-effects.[45]
Regenerative Medicine And Tissue Engineering
Muscarinic agonist medications such as pilocarpine and cevimeline
induced salivary secretion from the residual functional tissue. However,
they only provided temporary relief of symptoms and had a limited
effect on the recovery of damaged tissue. Accordingly, the development
of a novel treatment to restore or regenerate damaged salivary gland
tissue is eagerly awaited. Recently, the occurrence of proliferative,
multipotent salivary gland stem/progenitor cells has been reported in
neonatal mice. A similar cell type was also reported in adult mice,
although their pluripotency was limited.[46,47] More recently, the
potential of mesenchymal stem cells to regenerate salivary glands was
reported using a radiation-damage model.[47,48]
CONCLUSION
Without adequate salivary output, oral and pharyngeal health declines
along with a person's quality of life. Diagnosis of salivary disorders
begins with a careful medical history and examination of head and neck.
While complaints of xerostomia may be indicative of a salivary gland
disorder, salivary diseases can present without symptoms. Therefore,
routine examination of salivary function must be a part of any head,
neck, and oral examination. Therapies are designed to prevent the
development of oral and pharyngeal sequelae of salivary hypofunction.
Current xerostomia-based treatments include replacement therapies and
gustatory, masticatory, and pharmacological stimulants. Regenerative
medicine and tissue engineering may provide new treatment modalities
for atrophic salivary gland. However, such efforts are still in a very early
stage, and a more basic understanding of salivary gland tissue
regeneration and stem cells is required. Healthcare professionals can
play a vital role in identifying patients at risk for developing salivary
dysfunction, and should provide appropriate preventative and
therapeutic techniques that will help to preserve a person's health,
function, and quality of life.
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