Dry Mouth (Xerostomia)

Does your mouth feel dry and sticky when you first wake up in the morning? Do you feel the urge to drink lots of water? Dry mouth can make it hard for to swallow, chew your food or speak clearly. With a dry mouth your teeth can decay very quickly, and sometimes there are no warning signs for this condition. Untreated dry mouth and also contribute to bad breath, and sometimes other will notice the stale odour.

Dry mouth is the most common salivary problem. It can be due to reduced salivary flow (hypo salivation) +/or changed salivary composition.

Etiology

Iatrogenic

¨ Drugs (cytotoxics; anti-cholinergics-atropine, antidepressants, opioids, antihistamines, benzodiazepines; drugs acting on sympathetic system-ephedrine, antihypertensives; diuretics)

¨ Radiation (for neoplastic conditions in the head and neck)

Your physician or nurse do not always talk about dry mouth as a side effect when they give you a prescription for medicine. Whatever you do, don’t stop taking your medicine but mention dry mouth to your physician as soon as possible.

Disease

¨ Dehydration (diabetes mellitus, chronic renal failure, hyperparathyroidism, fever)

¨ Psychogenic (anxiety)

¨ Salivary gland disease (includes, Sjogren’s, sarcoidosis, HIV, Hepatitis C, primary biliary cirrhosis and cystic fibrosis)

¨ Sjogren’s syndrome (see below)

¨ Sarcoidosis

¨ Salivary aplasia (rare, children born without salivary glands)

Clinical Features

¨ Difficulty swallowing, controlling dentures, speaking

¨ Mouth soreness and dry lips and throat.

¨ Unpleasant taste, or loss of sense of taste

¨ Dry mucosa. It feels like your mouth is stuffed with cotton.

¨ Characteristic lobulated tongue-red with partial/complete depapillation resulting in a burning feeling and sometimes the tongue feels like shoe leather.

¨ Food debris sticking to teeth

¨ Lack of usual pooling in floor of the mouth

¨ Saliva not expressible from parotid duct

Complications

¨ Dental caries

¨ Candidiasis (+/or angular cheilitis)

¨ Halitosis (bad breath)

¨ Ascending suppurative sialadentitis (an infection in the salivary gland)

Investigations

¨ Sialometry (flow rate measurement)

¨ Sialography (radio-opaque dye introduced to salivary duct - shows dilatation, or duct obstruction)

¨ Salivary scintiscanning (radionuclide used to examine all major salivary glands simultaneously)

¨ Blood tests (ESR, SS-A (Ro) and SS-B (La) antibodies, rheumatoid factor (RF)-exclude Sjogren’s, blood glucose-exclude diabetes, serology- exclude hepatitis, serum ACE-exclude sarcoidosis)

¨ Eye tests – Schirmer –to exclude Sjogren’s

¨ Salivary gland biopsy (i.e. labial gland if suspicion of organic disease e.g. Sjogren’s)

¨ Imaging – CXR (exclude sarcoidosis), MRI (exclude Sjogren’s), Ultrasound (exclude Sjogren’s + neoplasia)

¨ Urinalysis – exclude diabetes

Comfort Tips & Management:

Sip room temperature water throughout the day and night and carry a water bottle with you at all times. Avoid drinking lots of water at an extreme temperature (very hot or very cold) Only drink sugarless drinks and avoid carbonated beverages. Avoid drinks with caffeine because caffeine can dry out the mouth. Drinking coffee, tea and diet soda occasionally is ok but don’t overdo it. While eating a meal, make sure you include a beverage like water. Drinking water before, during and after the meal. Chew sugarless gum or suck on sugarless candy to stimulate salivary flow. If you smoke or drink alcohol, don’t! both alcoholic beverages and smoking dry out the mouth and make you more susceptible to gum diseases and oral cancer. Select an alcohol-free over-the-counter mouth rinse if you are in the habit of using a mouthwash. Read the label and make sure alcohol is not listed in the ingredients. Try using night time humidifier to moisten room air. Any underlying cause rectified, if possible Avoid factors which increase dryness (alchol, smoking, dry foods) Mouth hydrated as often as possible (lip balm to lips) Synthetic Salivary substitutes

Glandosone (carboxymethylcellulose spray)

Luborant (carboxymethylcellulose spray)

Oral balance (lactoperoxidase)

Saliva Orthana (porcine mucin)

Sjogren’s Syndrome

The association of dry mouth and dry eyes with lymphoid infiltrate in exocrine glands and autoantibodies. It has 2 main forms:-

¨ Primary Sjogren Syndrome/Sicca Syndrome (SS-1) – absence of connective tissue disease, uncommon, worse oral symptoms, increased risk of lymphoma than SS-2

¨ Secondary Sjogren Syndrome (SS-2) – presence of connective tissue or autoimmune disease, more common

e.g. rheumatoid arthritis (RA), systemic lupus erythematosus, polymyositis, scleroderma, primary biliary cirrhosis

Uncommon, most common middle-aged or older, women more frequently

Viral aetiology

Clinical Features

¨ Eyes red with inflammation of conjunctivae, soft crusts at angles (Complaints of eye grittiness, soreness, itching, dryness, blurred vision)

¨ Lacrimal glands may swell

¨ Connective tissue disease (eg long-standing RA)

Complications

¨ Salivary gland enlargement

¨ Chronic B lymphocyte stimulation can occasionally lead to B-cell lymphoproliferation in mucosal-associated lymphoid tissue (MALT Lymphoma)

Management

¨ Followed up regularly because of possibility of lymphoma (Presents: firm tender salivary swelling, lymphadenopathy, cough, dyspnoea, hepatosplenomegaly, nodular lung lesions)