Xerostomia

Xerostomia is generally a symptom of various health conditions and a side effect of certain medications. It can present with other symptoms, including:

• Changes in taste perception, along with intolerance to spicy, salty, or sour foods and drinks
• Burning sensation in the mouth, accompanied by a sticky, dry, and rough tongue
• Difficulty in chewing, swallowing, tasting, or speaking
• Sore throat
• Atrophic, cracked, or chapped lips, in addition to peeling
• Mouth ulcers or sores
• Increased risk of infections in the mouth
• Hoarseness of the voice
• Bad breath or halitosis
• Increased dental cavities or decay
• Ineffectiveness in retaining dental dentures or other oral prostheses

Xerostomia is a condition in which the salivary glands produce less saliva, leading to a dry mouth. Some common causes include:

• Medications: This is the most common cause of xerostomia. Many over-the-counter medications list dry mouth as a side effect. Some medicines known to cause xerostomia include:
  • Medications for anxiety and depression
  • Anticholinergics used in the treatment of urinary incontinence, overactive bladder, and chronic obstructive pulmonary disorder
  • Decongestants and antihistamines used for allergies and colds
  • Pain medications
  • Drugs used to treat high blood pressure
  • Certain bronchodilators for asthma
  • Medications for diarrhea
  • Certain muscle relaxants
  • Medications for Parkinson's disease
  • Chemotherapy drugs for cancer treatment
• Radiation therapy: Radiation treatments to the head and neck for cancer can cause irreversible damage to the salivary glands, leading to a significant decrease in saliva production.
• Dehydration: Dehydration occurs when the body loses fluids without replenishment. This can happen during hot weather or due to vomiting, diarrhea, fever, excessive sweating, blood loss, or burns. Dehydration reduces saliva production, resulting in a dry mouth.
• Mouth-breathing or snoring: Breathing through the mouth due to nasal congestion or snoring while sleeping can cause saliva to evaporate, leading to dryness in the mouth.
• Medical conditions: Xerostomia can be a sign of various medical conditions, including:
  • Sjogren’s disease
  • Acquired immunodeficiency syndrome (AIDS)
  • Poorly controlled diabetes
  • Uncontrolled hypertension
  • Anemia
  • Hypothyroidism
  • Sinusitis
  • Sleep apnea
  • Cystic fibrosis
  • Mumps
  • Yeast infections
  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Parkinson's disease
  • Alzheimer's disease
  • Hepatitis C
  • Lymphoma
  • Chronic graft-versus-host disease in bone marrow transplant recipients
  • Salivary gland agenesis or aplasia
  • Stroke
• Aging: Individuals may experience xerostomia as they age due to factors such as medication use, changes in the body's ability to process medications, inadequate nutrition, or long-term health issues.
• Nerve damage: Injury, infection, or surgery that damages the nerves in the head or neck can lead to xerostomia.
• Smoking and drinking: Alcohol acts as a diuretic, leading to fluid loss. Smoking can also reduce salivary flow, contributing to dry mouth.
• Use of recreational drugs: "Meth mouth" is a condition associated with methamphetamine use that causes severe xerostomia and tooth damage. Other drugs, such as marijuana, can also lead to xerostomia.
• Stress and anxiety: Excessive cortisol production during stress or anxiety can alter saliva composition, resulting in a dry mouth.

Xerostomia can be a symptom of an underlying condition or an adverse effect of certain medications. It can be permanent or temporary depending on the cause. Some of the risk factors associated with xerostomia are:

• Medications like antidepressants and anxiolytics (anti-anxiety)
• Autoimmune conditions such as Sjogren’s disease and AIDS
• Old age
• Bulimia or anorexia
• Blockage of major salivary duct due to salivary stones or infection
• Smoking
• Chemotherapy and radiation to the head and neck
• Mouth breathing
• Patients with mental or nervous disorders
• Individuals wearing dentures
• Pregnancy or breastfeeding

Diagnosis of Xerostomia

The diagnosis of xerostomia is based on detailed:

Medical history

• Details about the duration, frequency, and severity of dry mouth are documented.
• The history of dryness at other sites (eyes, nose, throat, skin, and vagina) is obtained along with a complete prescription drug history, health conditions, and any other accompanying symptoms.

Physical examination

• Major salivary glands are examined for the presence of any pain, firmness, or enlargement.
• The amount and quality of saliva coming from the ducts inside the mouth is assessed.

Examination of the mouth

• There may be very little or no pooled saliva on the floor of the mouth. The saliva may appear stringy, ropy, or foamy.
• The presence of dry, sticky, or reddish oral mucosa is inspected. Occasionally, fungal or yeast infections may be present, appearing as removable white plaques on the inner mucosal surface of the mouth.
• The tongue may appear dry with decreased numbers of papillae.
• The extent and pattern of dental decay are evaluated. Multiple dental caries, especially at the neck of the teeth or the tips of the teeth, along with plaque accumulation and gum infections, can be seen.

Several office tests and techniques can be utilized to detect the abnormal functioning of the salivary glands. These tests are as follows:

1. Sialometry: Also known as salivary flow measurement, it is a simple procedure that measures the flow rate of saliva. In this test, collection devices are placed over the parotid gland or the submandibular/sublingual salivary gland at the opening of the duct, and saliva is stimulated with citric acid. The normal salivary flow rate for the parotid gland when it is not stimulated is 0.4 to 1.5 mL/min/gland. The normal flow rate for “resting” whole saliva is 0.3 to 0.5 mL/min; for stimulated saliva, it is 1 to 2 mL/min. Values less than 0.1 mL/min are generally considered xerostomic.
2. Sialography: An imaging technique that may be used to detect any masses or stones in the salivary gland. It involves the injection of a radio-opaque dye into the salivary glands.
3. Salivary scintigraphy: This can be useful in assessing salivary gland function. Technetium-99m sodium pertechnate is injected intravenously to ascertain the rate and density of uptake and the time of excretion in the mouth.
4. Biopsy: Minor salivary gland biopsy is often used in the diagnosis of Sjögren’s syndrome (SS), HIV-salivary gland disease, sarcoidosis, amyloidosis, and graft-versus-host disease (GVHD). Biopsy of major salivary glands is an option when malignancy (cancer) is suspected.
5. Blood tests: In addition to assessing the salivary glands, some blood tests may also help in detecting any underlying infection or disease. The tests include:
   • Complete blood count (CBC)
   • Blood sugar tests
   • Electrolyte levels

Though xerostomia is quite common, it can often be prevented. Here are a few tips to prevent it:

• Drink a minimum of 2L (i.e. 8 glasses of 250ml each) of water a day.
• Start using a humidifier in your home, especially in the bedroom.
• Breathe through the nose rather than through the mouth.
• Consult a physician before taking any over-the-counter medications such as antihistamines and decongestants.
• Avoid caffeinated beverages, tobacco, and alcohol, all of which increase dryness in the mouth.
• Do not consume any recreational drugs as they may cause severe xerostomia.
• Try maintaining and monitoring blood sugar levels in case of diabetes.
• Practice good oral hygiene.

Note: If someone has to undergo radiotherapy, surgical transfer of one submandibular salivary gland to the submental space (the deep compartment of the head and neck that lies in the midline below the chin) shields the gland during radiation therapy. Studies confirm that there is no adverse effect on the function of the gland in this position.

Xerostomia can be managed by several over-the-counter medications and products that aid in providing relief from the symptoms. These medications range from salivary substitutes and stimulants to products designed to minimize dental problems. They are as follows:

1. Saliva substitutes
   These can be used as artificial saliva to help replace lost moisture and lubricate the mouth. Available commercially or compounded, artificial salivas do not stimulate salivary gland production but mimic natural saliva, serving as replacement therapy rather than a cure. Salivary substitutes are available as solutions, sprays, gels, and lozenges. They generally contain agents to increase viscosity (such as carboxymethylcellulose or hydroxyethylcellulose), minerals (such as calcium and phosphate ions and fluoride), preservatives (such as methylparaben or propylparaben), and flavoring agents.
2. Saliva stimulants
   A recently developed product called Natrol Dry Mouth Relief contains a patented pharmaceutical grade of anhydrous crystalline maltose (ACM) used to stimulate saliva production. In a clinical study of patients with Sjogren's syndrome, ACM was shown to increase secretions. Natrol Dry Mouth Relief is formulated as lozenges that can be dissolved in the mouth three times daily. As it stimulates salivary glands, it is not recommended for patients whose salivary gland function has been lost due to radiation therapy.
3. Medications
   
   • Pilocarpine: A muscarinic (M3) agonist that stimulates saliva secretion. Indicated for the treatment of xerostomia symptoms due to salivary gland hypofunction caused by Sjogren’s syndrome or radiotherapy for head and neck cancer.
   • Cevimeline: A cholinergic agonist with high affinity for muscarinic M3 receptors on lacrimal and salivary gland epithelium, increasing exocrine gland secretions. Used to relieve xerostomia symptoms in patients with Sjogren’s syndrome. Note: These prescription medications should be avoided in patients with asthma and glaucoma.
4. Other medications and preparations
   The following medications are under clinical trial, and their efficacy is yet to be determined:
   • Anethole trithione: A bile secretion-stimulating drug (cholagogue) that stimulates the parasympathetic nervous system and increases acetylcholine secretion, resulting in enhanced salivation.
   • Yohimbine: An alpha-2 adrenergic antagonist that indirectly increases peripheral cholinergic activity, thus improving salivation.
   • Human interferon alfa (IFN-a): Currently undergoing clinical trials to determine the safety and efficacy of low-dose lozenges in the treatment of xerostomia in patients with Sjogren’s syndrome.

Home remedies for xerostomia help in managing the symptom and provide relief; however, these cannot be considered a cure.

1. Try over-the-counter saliva substitutes or oral lubricants: Many different brands of salivary substitutes or oral lubricants are available. They do not cure xerostomia but provide some relief and assist during eating and speaking.
2. Drink a lot of water: Sipping water and staying hydrated can help relieve the symptoms and discomfort caused by xerostomia. Studies have shown that dehydration may be a causative factor in xerostomia, and increasing water intake can help treat mild dehydration.
3. Avoid certain medications: The most common cause of xerostomia is the use of certain medications. Consult your doctor to determine if your medications are causing dryness in the mouth. Do not stop any medications abruptly without consulting your doctor. Medications that may cause dry mouth include:
   • Antianxiety medicines
   • Anticonvulsants
   • Antidepressants
   • Antihistamines
   • Antipsychotics
   • Sedatives
   • Smoking-cessation agents
   • Urinary incontinence agents
   • Bronchodilators
   • Decongestants
   • Diuretics
   • High blood pressure medications
   • Muscle relaxants
   • Narcotic analgesics
   • Nonsteroidal anti-inflammatory drugs
   • Opioid analgesics
   • Parkinson’s disease medications
4. Say no to dehydrating habits: Common ways to prevent dehydration and thereby xerostomia include:
   • Quit smoking
   • Avoid caffeine
   • Limit alcohol use
   • Decrease sugar intake
5. Give importance to overall oral care: Xerostomia can be both a symptom and a cause of poor oral hygiene. Maintaining good oral hygiene is crucial in managing xerostomia. This includes frequent flossing, using fluoride toothpaste, and utilizing mouthwash. When choosing a mouthwash, ensure it does not contain alcohol, as alcohol-based mouthwashes can increase dryness. Mouthwashes containing xylitol can help prevent dental caries. Since dry mouth can lead to fungal infections like oral candidiasis, antifungal mouth rinses and dissolving tablets may be required. Dentures should be soaked daily in a chlorhexidine solution to prevent fungal infections.
6. Try sugarless candies or gums: Sucking on sugar-free candies or products like chewing gums, cough drops, and lozenges may provide short-term relief from xerostomia. Citrus, cinnamon, or mint-flavored candies are good choices. Some sugarless gums and candies also contain xylitol, which can help prevent dental cavities.
7. Use lip balms frequently: Moisturizing the lips with a lip balm or petroleum jelly every two hours can be beneficial.
8. Dietary modifications: Moisten foods with gravy, soups, sauces, creams, ghee, or butter. Taking sips of water or fluids while eating can help soften the food. Aim for foods that are at room temperature and restrict salty and dry foods like toast, cookies, dry breads, dry meats, dried fruits, and bananas. Avoid foods and beverages with high sugar content.
9. Avoid mouth breathing consciously: Mouth breathing can exacerbate xerostomia and may lead to other oral health problems.
10. Use a humidifier: Creating a humid environment may help relieve xerostomia by adding moisture to the surroundings.

Xerostomia can often be a contributing factor for both minor and serious health problems. It can affect nutrition, dental, and psychological health. Some of the common problems associated with xerostomia include:

• Constant sore throat
• Burning sensation in the mouth
• Halitosis or bad breath
• Difficulty speaking and swallowing
• Hoarseness of voice
• Dry nasal passages
• Excessive plaque accumulation
• Gum diseases
• Dental caries
• Oral candidiasis

1. Home Remedies

• Aloe Vera: The gel or juice inside the aloe vera plant is very moisturizing. Drinking aloe vera juice can provide relief from xerostomia.
• Ginger: Ginger is known to help stimulate salivary production.
• Homemade Mouthwash: Blend 1 cup of warm water with 1/4 teaspoon of baking soda and 1/8 teaspoon of salt. Rinse your mouth for a few seconds, then rinse with water. Repeat every 3 to 4 hours.

2. Oil Pulling

Oil pulling is an ancient Ayurvedic technique that involves holding a few tablespoons of coconut or sesame oil in the mouth for 10 to 15 minutes without swallowing. This method can help clean the mouth and soothe irritated spots, providing relief from xerostomia.

3. Unani Therapy

According to Unani therapies, the best way to manage xerostomia is through lifestyle modifications. This is based on Setteh-e-Zarurieah, which emphasizes consuming foods that are moisturizing in nature, such as:

• Rice cooked with milk
• Fresh fish
• Goat meat
• Foods prepared with pumpkin and spinach
• Purslane

The best foods for patients with xerostomia include almonds, figs, grapes, peaches, and fresh broad beans.

4. Acupuncture

In acupuncture, an acupuncturist inserts thin, disposable needles into the skin to enhance energy flow to the mouth and throat. However, acupuncture as a therapy requires further studies and scientific validation.

Xerostomia is a condition that causes dryness of the mouth. It can be mild or severe depending on the cause. Xerostomia can be treated with salivary substitutes, salivary stimulants, and medications. In addition to these treatments, the symptoms of xerostomia can be managed by following certain simple tips:

• Drink at least 8 glasses of water every day
• Avoid medications that cause dry mouth
• Try sugarless candies or gums
• Limit the intake of caffeine and alcohol
• Decrease sugar intake
• Maintain a good oral hygiene regimen
• Use a non-alcohol based mouthwash
• Try over-the-counter saliva substitutes or oral lubricants
• Moisturize lips with a lip balm
• Eat foods with creams, ghee, or butter
• Restrict eating salty and dry food items
• Avoid breathing through the mouth continuously
• Use a humidifier in the house
• Quit smoking
• Get proper sleep
• Avoid walking in the sun or excessive exercise

Furthermore, patients with xerostomia should avoid stresses such as anger, sorrow, and excessive fear. If the symptoms persist, consult a dentist or a physician to understand the root cause and manage the symptoms.