Xerostomia in geriatric patients: a burgeoning global concern

Saliva plays a key role in maintaining oral homeostasis, function, and health. The prevalence of xerostomia and its consequences are rising due to the increasing aging population, the effects of some systemic diseases, medical management, and commonly‐prescribed medications that reduce saliva production. When salivary function is diminished, patients are at a greater risk of developing caries, discomfort in wearing dentures, and opportunistic diseases, such as candidiasis. The psychosocial aspects of xerostomia can range from a mild effect on self‐rated oral health to frustration, embarrassment, unhappiness, or substantial disruptions in quality of life. This article reviews the clinical features, diagnosis, and prevalence of dry mouth, as well as its treatment strategies.     

Managing xerostomia and salivary gland hypofunction: Executive summary of a report from the American Dental Association Council on Scientific Affairs

Background and OverviewXerostomia, also known as “dry mouth,” is a common but frequently overlooked condition that is typically associated with salivary gland hypofunction, which is the objective measurement of reduced salivary flow. Patients with dry mouth exhibit symptoms of variable severity that are commonly attributed to medication use, chronic disease and medical treatment, such as radiotherapy to the head and neck region. Chronic xerostomia significantly increases the risk of experiencing dental caries, demineralization, tooth sensitivity, candidiasis and other oral diseases that may affect quality of life negatively. This article presents a multidisciplinary approach to the clinical management of xerostomia, consistent with the findings of published systematic reviews on this key clinical issue.Conclusions and Practice ImplicationsInitial evaluation of patients with dry mouth should include a detailed health history to facilitate early detection and identify underlying causes. Comprehensive evaluation, diagnostic testing and periodic assessment of salivary flow, followed by corrective actions, may help prevent significant oral disease. A systematic approach to xerostomia management can facilitate interdisciplinary patient care, including collaboration with physicians regarding systemic conditions and medication use. Comprehensive management of xerostomia and hyposalivation should emphasize patient education and lifestyle modifications. It also should focus on various palliative and preventive measures, including pharmacological treatment with salivary stimulants, topical fluoride interventions and the use of sugar-free chewing gum to relieve dry-mouth symptoms and improve the patient's quality of life.     

Xerostomia and associated factors in a community-dwelling adult population

Abstract Xerostomia is the subjective sensation of dry mouth. Estimates on the occurrence of xerostomia in community-dwelling adults have ranged from 10% among persons over age 50 to 40% for persons over age 65. Virtually no data are available for persons under age 50. To begin to establish a database on the occurrence of xerostomia and factors associated with it, a cross-sectional assessment of self-reported symptoms and salivary function was conducted across a broad age-range of generally healthy community-dwelling adults. A convenience sample of 710 adults who ranged from 19 to 88 years of age was drawn from various sources in the greater-Rochester, New York area. Study volunteers were administered a standardized questionnaire on general and oral health, which included questions on the symptoms of xerostomia, and were provided an oral screening examination, which included measurement of unstimulated and stimulated whole saliva flow rates. Overall, the observed prevalence of xerostomia was 24% among females and 18% among males. While xerostomia was more commonly observed in women than men, this association was only clear after age 50. Xerostomia was associated with: use of medications with hyposalivatory side-effects; difficulty with dry foods; cracked lips; dry eyes; difficulty swallowing; and, among males, current cigarette smoking. Results indicated a tendency for salivary flow rates to be lower for older persons, particularly the stimulated flow rate. There was a tendency in the younger cohorts for flow rates to be lower among individuals who reported sensation of dry mouth than among those who did not. This tendency was not apparent among older persons, suggesting that younger persons may be more likely to experience symptoms of oral dryness when salivary flow was low while older persons may relate symptoms of dry mouth to a more complex constellation of factors where salivary flow is only one component. These findings need to be examined further.     

Salivary secretion in health and disease

Saliva is a complex fluid produced by 3 pairs of major salivary glands and by hundreds of minor salivary glands. It comprises a large variety of constituents and physicochemical properties, which are important for the maintenance of oral health. Saliva not only protects the teeth and the oropharyngeal mucosa, it also facilitates articulation of speech, and is imperative for mastication and swallowing. Furthermore, saliva plays an important role in maintaining a balanced microbiota. Thus, the multiple functions provided by saliva are essential for proper protection and functioning of the body as a whole and for the general health. A large number of diseases and medications can affect salivary secretion through different mechanisms, leading to salivary gland dysfunction and associated oral problems, including xerostomia, dental caries and fungal infections. The first part of this review article provides an updated insight into our understanding of salivary gland structure, the neural regulation of salivary gland secretion, the mechanisms underlying the formation of saliva, the various functions of saliva and factors that influence salivary secretion under normal physiological conditions. The second part focuses on how various diseases and medical treatment including commonly prescribed medications and cancer therapies can affect salivary gland structure and function. We also provide a brief insight into how to diagnose salivary gland dysfunction.     

Xerostomia: etiology,recognition and treatment

BACKGROUND: Clinicians may encounter symptoms of xerostomia, commonly called "dry mouth," among patients who take medications, have certain connective tissue or immunological disorders or have been treated with radiation therapy. When xerostomia is the result of a reduction in salivary flow, significant oral complications can occur. TYPES OF STUDIES REVIEWED: The authors conducted an Index Medicus--generated review of clinical and scientific reports of xerostomia in the dental and medical literature during the past 20 years. The literature pertaining to xerostomia represented the disciplines of oral medicine, pathology, pharmacology, epidemiology, gerodontology, dental oncology, immunology and rheumatology. Additional topics included the physiology of salivary function and the management of xerostomia and its complications. RESULTS: Xerostomia often develops when the amount of saliva that bathes the oral mucous membranes is reduced. However, symptoms may occur without a measurable reduction in salivary gland output. The most frequently reported cause of xerostomia is the use of xerostomic medications. A number of commonly prescribed drugs with a variety of pharmacological activities have been found to produce xerostomia as a side effect. Additionally, xerostomia often is associated with Sj?gren's syndrome, a condition that involves dry mouth and dry eyes and that may be accompanied by rheumatoid arthritis or a related connective tissue disease. Xerostomia also is a frequent complication of radiation therapy. CONCLUSIONS AND CLINICAL IMPLICATIONS: Xerostomia is an uncomfortable condition and a common oral complaint for which patients may seek relief from dental practitioners. Complications of xerostomia include dental caries, candidiasis or difficulty with the use of dentures. The clinician needs to identify the possible cause(s) and provide the patient with appropriate treatment. Remedies for xerostomia usually are palliative but may offer some protection from the condition's more significant complications.     

A review and guide to drug‐associated oral adverse effects—Dental,salivary and neurosensory reactions. Part 1

Numerous adverse drug reactions (ADR) manifest in the oral cavity and orofacial region. Dentists and other health professionals commonly encounter and manage these adverse effects however, due to lack of awareness and training, they are not always recognised as being drug‐induced nor reported to pharmacovigilance agencies. The broad diversity and increasing number of medications for which dental pharmacovigilance is needed can be overwhelming for all health professionals. Thus, the aim of this review and guide was to outline the common medications associated with orofacial side effects so as to improve recognition, management and reporting of ADR. Adverse effects discussed in Part 1 include drug‐induced bruxism, tardive dyskinesia, hairy tongue, gingival enlargement, hypersalivation, xerostomia, tooth discolouration and taste disturbance.     

Review of the use of polymers in saliva substitutes for symptomatic relief of xerostomia

It is clear from the many clinical studies carried out on currently available saliva substitutes, that the main factors limiting the success of polymers in treating xerostomia is their short duration of action and/or their lack of acceptability by users. The most effective formulations for severe sufferers of xerostomia contain relatively viscous, thixotropic polymers, which mild to moderate sufferers in particular tend to dislike. Relief can also be extended by increasing concentrations of non-thixotropic polymers; however, this also has to be balanced by the decrease in palatability resulting from higher polymer levels. In addition, gels rather than solutions tend to result from higher polymer concentrations, which are only employed by the most severe sufferers of xerostomia, and in fact, have been suggested to offer little improvement in efficacy over oral sprays. It would be highly advantageous to improve the duration of relief without impacting negatively on the sensory profile of the product. This would provide a longer lasting effect that is acceptable to all sufferers of xerostomia. The essential role of polymers in saliva substitutes is to provide lubrication, hydration, and protection of the oral mucosa, providing symptomatic relief to sufferers of xerostomia. However, saliva substitutes should also be of neutral or near neutral pH, to prevent demineralization of the oral hard tissues. These products should always be used in conjunction with a thorough oral health regimen, but may also contain appropriate levels of electrolytes for remineralization of enamel and dentine.     

Hyposalivation and Xerostomia in Dentate Older Adults

BackgroundOlder adults are susceptible to reduced saliva production related to certain medications, radiation and chronic conditions. Many of these people have many physical and oral health problems and limited access to dental care. The use of effective screening tools for xerostomia and hyposalivation would be helpful in identifying those at risk. The authors conducted a study to investigate the association between three measures of oral dryness: hyposalivation (low unstimulated salivary flow), self-reported xerostomia and clinically assessed dry mouth.MethodsThe authors included a convenience sample of 252 nondemented and dentate West Virginia participants 70 years and older who were part of a larger study on oral health and cognition among older adults. Participants completed a self-reported xerostomia index, provided an unstipulated salivary sample and underwent an oral assessment for the study.ResultsTwenty-eight participants (11.1 percent) had hyposalivation, eight of whom reported having xerostomia (sensitivity = 28.6 percent). Of the 43 participants who reported having xerostomia, only eight had hyposalivation (positive predictive value = 18.6 percent). Hyposalivation and self-reported xerostomia were not significantly related. Clinically assessed dry mouth correlated modestly, but significantly, with hyposalivation and self-reported xerostomia.ConclusionsObtaining routine unstimulated salivary flow rates in addition to self-reported information and oral evaluations may increase early detection of oral dryness, which would assist in implementing early interventions to improve patients' quality of life.Clinical ImplicationsVisually inspecting oral tissues for dryness and asking a patient if his or her mouth is dry are insufficient measures for clinicians to use to determine if the patient has hyposalivation. The authors recommend that clinicians determine the patient's unstimulated salivary flow rate.     

Oral health condition and saliva flow in southern Chinese with Sjögren's syndrome

Objective : To investigate the oral health condition and saliva flow of southern Chinese patients with Sjögren's syndrome (SS). Method : 51 SS patients (26 primary and 25 secondary cases) and 29 controls took part in this cross‐sectional study. Stimulated whole and parotid saliva flow rates, pH, and buffer capacity, and xerostomia, oral mucosal lesions, oral hygiene status, dental and periodontal conditions, prosthetic status were assessed and compared between groups. Results : Stimulated whole saliva (SWS) flow was reduced in primary and secondary SS cases (p<0.001), pH and buffer capacity were also reduced in the primary SS group (p<0.05). SS patients had a greater prevalence of xerostomia than controls (p<0.001). Primary SS patients had a higher mean DMFT, more missing teeth, and more prostheses than secondary SS cases and controls (p<0.05). SWS flow correlated negatively with the number of filled teeth in both SS groups (p<0.05) and the number of decayed teeth in the primary SS group (p<0.05). Conclusion : Despite good oral hygiene and regular dental checkups, the oral health of southern Chinese with primary SS was significantly compromised compared with secondary SS cases and controls, most probably due to the combined effect of impaired salivary gland function and poorer saliva buffer capacity.     

Identifying and treating xerostomia in restorative patients.

Inadequate saliva can have devastating consequences for a patient, including oral discomfort, rampant caries, increased candida infections, and desiccation of restorative and esthetic dental treatment. Diagnosis of the cause of xerostomia is imperative to treating the condition, and multiple causes should be considered. Treatment options for xerostomia consists of treatment for hyposalivation, palliative and preventive care to combat the results of long-term dry mouth. Treatment of xerostomia should be based on the etiologic factors of the disease, with prevention of further oral destruction and comfort being the primary goals of treatment.     

Pilocarpine treatment in a mixed cohort of xerostomic patients

Objective: To compare the effect of a single 5‐mg dose of pilocarpine hydrochloride on the salivary flow rate in three groups of xerostomic patients. Subjects and methods: Forty‐five patients were divided into three groups according to the etiology of their xerostomia: (i) radiotherapy; (ii) Sjögren's syndrome; and (iii) sialosis and xerogenic medications. Following the oral administration of a 5‐mg pilocarpine hydrochloride tablet blood pressure, heart rate, body temperature and saliva secretion rates were monitored hourly for 3 h and adverse events were reported. Results: The most significant and persistent elevation of salivary flow rate was observed in the sialosis/drug‐induced group followed by the Sjögren's syndrome group. The radiotherapy group presented a significant elevation of salivary secretion rate after 1 and 2 h, but returned to baseline at 3 h. No significant changes in vital signs were reported, except for low diastolic pressure measured at 1 h in the radiotherapy group. Several adverse events were recorded throughout the trial; however, only one patient withdrew from the study. Conclusion: Treatment with pilocarpine hydrochloride tablets may improve saliva secretion in patients taking xerogenic medications and/or suffering from metabolic sialosis expanding the beneficial potential of this sialogogue.     

Salivary secretion, taste and hyposalivation

Summary Saliva has many essential functions. As the first digestive fluid in the alimentary canal, saliva is secreted in response to food, assisting intake and initiating the digestion of starch and lipids. During this process, saliva acts as a solvent of taste substances and affects taste sensitivity. Clinically, a more important role is in the maintenance of oral health, including the protection of teeth and mucosa from infections, maintenance of the milieu of taste receptors, and communication ability through speech. Variations in salivary flow can be affected, reversibly or irreversibly, by numerous physiological and pathological factors. Decreased salivary flow results in clinically significant oral discomfort that may manifest as increased caries, susceptibility to oral candidiasis, altered taste sensation or as a host of other problems. Hyposalivation is a condition that is frequently encountered in dental practice. The most common cause is the use of certain systemic medications, which put the elderly at greater risk because they are usually more medicated. Other causes include high doses of radiation and certain diseases such as Sjögren’s syndrome. This article reviews the mechanism of salivary secretion, effect of saliva on taste, importance of saliva in oral health, and hyposalivation in relation to ageing, medicine and/or disease and management of hyposalivation.     

Identifying and Treating Xerostomia in Restorative Patients

Abstract: Inadequate saliva can have devastating consequences for a patient, including oral discomfort, rampant caries, increased candida infections, and desiccation of restorative and esthetic dental treatment. Diagnosis of the cause of xerostomia is imperative to treating the condition, and multiple causes should be considered. Treatment options for xerostomia consists of treatment for hyposalivation, palliative and preventive care to combat the results of long-term dry mouth. Treatment of xerostomia should be based on the etiologic factors of the disease, with prevention of further oral destruction and comfort being the primary goals of treatment.     

Medication-induced hyposalivation: etiology, diagnosis, and treatment

Polypharmacy in the nation's growing geriatric population will require increasingly complex pharmacologic management of multiple disease states. This brief review describes normal salivary function, potential causes of salivary dysfunction, oral health concerns associated with hyposalivation, diagnostic tests, and options for patient care. Medications can reduce salivary flow, creating the condition known as xerostomia. A major complication of xerostomia is the promotion of dental caries. Asking several standardized questions regarding symptoms may help confirm salivary gland hypofunction. The general approach to patients with hyposalivation and xerostomia is directed at palliative treatment for the relief of symptoms and prevention of oral complications.     

Xerostomia: evaluation of a symptom with increasing significance

Xerostomia is the subjective sensation of oral dryness. Although it is most commonly associated with salivary gland dysfunction, it may also occur with normal gland activity. Xerostomia may be an early symptom of several morbid systemic conditions with important implications for the medical and dental management of patients. Oral dryness also has negative effects on an individual's emotional well-being and quality of life. The complaint of xerostomia necessitates a complete evaluation of a patient's general health, salivary gland function, and oral motor and sensory abilities. The salivary gland assessment includes symptom review, analysis of glandular secretions, scintiscanning, and minor labial gland biopsy. No single component is sufficient to adequately diagnose the presence, extent, or cause of salivary dysfunction. Treatment of a dry mouth, to date, is mainly palliative in nature, with the intent of preserving oral structures and functions. Better therapies are essential in the management of xerostomia, whatever the cause. The importance of xerostomia as a symptom is increasingly recognized in medicine and dentistry. The dentist is commonly the first health professional to hear this complaint and may be critical in directing a full and appropriate evaluation.     

The role of saliva in maintaining oral homeostasis

Dental practitioners are becoming more cognizant of the importance of saliva as they treat a greater number of older patients, especially those with medical problems requiring a variety of medications that have xerostomia as a side effect. This article discusses salivary composition and function in a broad perspective, relating them to clinical concerns and current research. Understanding the role of saliva in maintaining health, as well as its relation to oral disease, is vital to the competent dental practitioner.     

Access to special care dentistry, part 4. Education

Many groups of patients with disabilities have a higher risk of oral disease due to compromised oral hygiene as a consequence of their impairment, oral manifestations of their particular condition and/or the side effects of drug regimes, notably xerostomia and sugar in medicines. This article looks at education related to oral health and its management for both patients and carers. It will encourage a tailored routine for oral hygiene, taking account of the best time of day for the person concerned, the facilities available to them, appropriate preventive measures and the support and adaptations required to minimise the effect their impairment has on managing their oral hygiene. Additionally, it considers educational issues for the dental team related to some elements of managing oral health of people with disability, the dental team's responsibility in educating other health professionals and the availability of undergraduate and postgraduate education in special care dentistry.     

Survey of oral nursing care attitudes,knowledge and practices in a neurorehabilitation setting

The provision of oral care is an important fundamental nursing activity. The purpose of the study was to gain knowledge on nursing care professionals´ attitude, belief, knowledge and practice towards oral care in a neurorehabilitation setting. Nursing care professionals (n = 260, response rate: 60%) at neurorehabilitation hospital took part in cross‐sectional web‐based 59‐items survey. Attitudes were cross‐tabulated and compared using Fisher's exact test. Oral care product frequencies were compared between patients with/without eating difficulties using McNemar's test. Most professionals agreed that oral health impacts general health (93%) and poor oral health can cause pneumonia (85%). 41% professionals found it difficult to clean the oral cavity and 12% found it unpleasant. 40% indicated that time allocated for oral hygiene was insufficient, 27% indicated a need for broader range of oral care supplies and >80% would like continuing oral care education. Manual toothbrush and toothpaste were used more than once per shift by >75% in all patients. Swabs, premixed mouth rinse, carbonated water and lip moisturiser were more frequently used in patients with eating difficulties compared to with no eating difficulties. Oral care is perceived as an essential component of care in neurorehabilitation. However, professionals indicated lack of time, need for better supplies and oral care training. The differentiated use of oral care products shows that professionals were aware that patients with eating difficulties have different requirements; however, some oral care practices were inappropriate. The results should be considered while designing oral care guidelines and training.     

Saliva in health and disease: an appraisal and update

Saliva plays an important role in oral health monitoring, regulating and maintaining the integrity of the oral hard tissues and some soft tissues. This paper reviews the role of saliva, the prevalence of oral dryness and the consequent importance of salivary flow as well as the relationship between xerostomia and salivary gland hypofunction amongst the causes of oral dryness. Other aspects of oral conditions associated with saliva are also reviewed including Sjögren's Syndrome and oesophageal function. Finally, knowledge, and the current use of salivary tests and the utilisation of saliva as a diagnostic fluid are surveyed.     

Unstimulated whole saliva flow rate in relation to sicca symptoms in Hungary

Objective: To assess the prevalence of xerostomia and the related oral and extraoral dryness symptoms in Hungary, to evaluate the association of those symptoms with the unstimulated whole saliva (UWS) flow rate, and to find correlation between the level of UWS flow rate and the oral health status of the questioned patients. Subjects And Methods: A total of 600 patients between the age of 18 and 92 years, 265 male, 335 female, were selected in accordance with the current regional age and residence distribution scheme of the Hungarian Statistical Office. A questionnaire was designed to determine the subjective presence or absence of the sicca symptoms. UWS flow rate and the dental and periodontal status were determined. Results: The percentages of subjective symptoms in the questioned subjects were oral dryness, 34%; reduced salivation, 11%; mucous saliva, 15%; dysphagia, 13%; glossopyrosis, 7%; dysphonia, 31%; dysgeusia, 9%; nasal dryness, 32%; ocular dryness, 21%; itching, 40% and xeroderma, 60%. Vaginal dryness was 14%, vaginal itching was 16% in the interviewed women. The grade of xerostomia, dysphagia, tiredness, and additionally the gingival bleeding index showed a negative correlation with the UWS flow rate. After all decayed, missing and filled teeth (DMF‐T) mean values, gingival bleeding index and plaque index were significantly higher in hyposalivators, compared with those who had normal flow rates Conclusion: This cross sectional study, representative of the Hungarian population, clearly shows that one‐third of the adult population suffers from xerostomia. The clinical severity of the xerostomia demonstrated a strong relationship with the lower levels of UWS flow rate. Reduced levels of UWS flow rate in this study were also shown to be associated with dysphagia, fatigue, and increased DMF‐T numbers. The data show that oral dryness, its associated desiccation symptoms and its clinical manifestations are significant health problems in Hungary.