Scope - Communication Resource Centre

Saliva Management

Dry Mouth Syndrome (Xerostomia)

Signs and Symptoms of Dry Mouth
Causes of Dry Mouth
Treatment of Dry Mouth
References

Dry mouth, sometimes referred to by the term xerostomia, occurs when there is a problem with the salivary glands, resulting in decreased saliva production. This impacts on various processes, including, speaking, taste, chewing, swallowing, oral hygiene and the wearing of dentures. It also results in oral discomfort. Dry mouth occurs in about 10% of the population and is a symptom rather than a disease on it's own. There are various causes of dry mouth, and it is essential to establish the cause before determining how to treat it. Listed on this website will be the signs and symptoms of dry mouth, a list of causes, and a list of different treatments.

Signs And Symptoms Of Dry Mouth

Oral signs and symptoms often associated with Dry Mouth:

Saliva is thick, ropy and reduced in amount
Painful sensation in the tongue
Coating of the tongue
Cracked, dry or scaled lips
Dry cheeks
Inflamed, painful and infected salivary glands
Increase in dental caries or decay
Infection of the gums
Difficulty with chewing, especially dry foods
Difficulty with swallowing (dysphagia)
Difficulty with speech
Impaired taste (dysgeusia)
Bad breath (halitosis)
Oral Thrush (Candidiasis)
Difficulty with managing dentures

Other bodily signs and symptoms often associated with Dry Mouth:

Dry, crusty nose with decreased sense of smell
Dry, itchy eyes, with sticking of lids together, blurred vision, light over- sensitivity
Dry throat, persistent dry cough
Arthritis, pain, swelling and stiffness of the joints
Constipation
Acid reflux
Dry, itchy, burning vagina/vulva, frequent fungal infections
Difficulty breathing
Weight loss, depression, fatigue, weakness, general aching, depression

Causes Of Dry Mouth

The following are causes for a decrease in production of saliva, resulting in dry mouth:

Medications-
There are over 600 medications that can cause the salivary glands to produce less saliva. Anticholinergic, antidepressant, antihistamines and diuretics are just some. If you are at all concerned that your medication may be causing dry mouth, see your doctor. For a list of medications.

Radiotherapy and Chemotherapy-
This is in particular for patients with head and neck cancer. You should speak to your doctor, speech pathologist or clinical care nurse if you are experiencing dry mouth whilst undertaking treatment.

Salivary duct stones-
These result in blockages of the salivary glands, ceasing the flow of saliva. If you believe this be the cause of your dry mouth, please speak to your doctor, speech pathologist or specialist.

Tumors or other obstructions-
Generally a tumor will only affect one salivary gland, therefore the other glands will continue to secrete saliva. If you believe this be the cause of your dry mouth, please speak to your doctor, speech pathologist or specialist.

Nerve damage-
Damage to the nerves which innervate the salivary glands can affect the amount or type of saliva produced, depending upon which gland is affected. Damage can result from surgery, physical injury or compression from tumors located in the head or neck region. If you believe this be the cause of your dry mouth, please speak to your doctor, speech pathologist or specialist.

Dehydration-
Dehydration can result from any number of causes, ranging from blood loss, renal failure of modified dietary intake which does not allow sufficient hydration. Lack of fluid in the body results in decreased amounts and thick, ropey saliva being produced.

Inflammation of salivary glands-
Inflammation of the salivary glands can result from infection in the oral cavity i.e. stomatitis, (see Altered Secretions for more information). Any inflammation of the glands will constrict the opening of the gland, decreasing the flow of saliva. Your dentist or doctor can be consulted if you are experiencing any infection in the oral cavity.

Syndromes or diseases-
The major disorder that affects saliva production is an autoimmune disease Sjogren's Syndrome, which destroys mucous producing glands (including salivary glands). Other diseases which may result in a dry mouth are:
AIDs
Parkinson's Disease
Diabetes
Bone Marrow Disorders
You should speak to your doctor or specialist if you are experiencing dry mouth as a secondary symptom to a disease

Limited Stimulation of the salivary glands-
The glands are stimulated to produce saliva when chewing occurs. Limited chewing, for any reason, can result in decreased stimulation of the salivary glands, and therefore decreased salivation.

Mouth breathing-
People who breathe through their mouth as opposed to their nose often experience dry mouth due to air drying out the mucosal lining of their mouth.

Treatment Of Dry Mouth

Treating the Symptoms
Treating the Causes

Before treatment can begin it is important to identify the xerostomic condition and the cause. Treating the cause of the dry mouth can eliminate the symptoms. However, in many cases, it will be difficult to eliminate the cause of the dry mouth, for example, in the case of nerve damage, auto-immune diseases such as Sjogren's Syndrome, or chemotherapy and radiotherapy. Therefore, symptomatic treatment that will lessen the effects of the condition is the next best option. It is very important to work closely with an appropriate health professional, e.g doctor, dentist, speech pathologist, when deciding on suitable treatment options for you. Particularly, if problems are medication-related, doctors must be consulted before any alteration to your drug regime is made.

Treating the Symptoms of Dry Mouth

General Behavioural or Palliative Treatments
Maintaining Good Oral Hygiene
Treatment Products available from Chemists
Alternative Treatments

There are many ways in which the symptoms of dry mouth can be relieved. Some you can do at home, others you will need to consult a doctor or other appropriate health practitioner before beginning any treatment regime.

General Behavioural Or Palliative Treatments

Carry a water bottle with you and sip water frequently throughout the day
Keep fluids at bedside at night
Use a humidifier at night (start at least 1 hr before bedtime, run through night)
Sleep on your side to reduce mouth breathing
Chew sugar-free gum regularly
Suck sugar-free lollies
Suck ice cubes
Drink fluids before, during and after meals (these should be low in sugar and acid content due to adverse effects of dental caries and dental erosion)
Include plenty of sauces and gravy with meals
Include foods with a high fluid content, such as soft puddings, jelly and pureed fruits
Use a petroleum based lubricant to moisturize lips during the day and at bedtime
Always rinse your mouth with plain water after eating or drinking
Consuming fruit products, such as pineapple chunks or juice, dark grape juice, horse-radish or paw paw extract have been reported to assist with xerostomia. However, some may have side effects so consult with your doctor prior to use
Visit your dentist regularly
If you wear dentures, and have trouble retaining them, use an adhesive oral product available from chemists to assist with this. E.g. Fixodent, Polident Denture Adhesive

Substances that increase oral dryness and therefore should be avoided:

Tobacco and alcohol
Caffeine, soft drinks
Foods with high sugar content
Dry foods such as crackers and biscuits
Spicy food
Hot food
Citric fruits or other substances high in acidic content

Maintaining Good Oral Hygiene

A good oral hygiene regime is essential for maintaining oral health. Saliva has a major role in this process.

Reduced saliva production can thus result in a build-up of bacterial plaque, leading to dental caries and gum disease. Although individuals with reduced saliva production are more susceptible to these types of problems, a good oral hygiene routine that helps to prevent bacterial accumulation can limit the harm caused by reduced salivary flow.

Saliva and GORD
Saliva neutralises acids in the mouth and pharynx. This is important for people suffering from Gastro-Oesophageal Reflux Disease (GORD), as acid reflux rises up into the pharynx and sometimes even into the mouth. An acid environment in the mouth produces increased caries and may be harmful to the gums. It may also increase the possibility of bad breath. The saliva provides a protective wash to help neutralise the acid.

Instruments and Procedures for a good oral hygiene routine:

Tooth brushing:
Tooth brushing helps to remove bacteria, plaque and prevent tooth decay and gum disease. Guide to effective brushing:

brush at least twice a day with a fresh, soft toothbrush and fluoride toothpaste
replace tooth brush every 3-6 months
brush with a gentle circular motion - scrubbing backwards and forwards can cause tooth wear
brush in a systematic manner to ensure that all teeth are brushed
ensure that all surfaces of the tooth get brushed
ensure brushing to the gum level

Flossing:
Flossing eliminates the bacteria and plaque that may lead to infection and that brushing alone often cannot reach.
Guide to effective flossing:

get a length of floss and wrap each end around each middle finger
gently work the floss between two teeth past the point where they contact
wrap slightly around one tooth and slide up and down the surface three or four times
repeat this procedure for every tooth
do this at least once a day

For those who find using this method difficult, flossettes are disposable floss holders which are very easy to use. These are available in various forms at supermarkets and chemists

Mouthwashes:
Using a mouthwash complements the benefits of brushing and flossing. A mouthwash will:

Remove oral debris
Lubricate tissues
Have an anti-bacterial and anti-septic effect
Be available in a spray or gel or mouthrinse form
(Factors that may influence use of a gel/spray/wash may include convenience, physical disability, motivation to comply etc.)

Common and effective mouthwashes used contain:
Chlorhexidine gluconate
Cetylpyridinium chloride
NB: often commercial mouthwashes contain a high alcoholic content - this can be erosive to oral tissue and can worsen the oral condition. Therefore, avoid mouthwashes of this kind, using to mouthwashes with a more neutral base.

Fluoride Gel:
A fluoride gel contains ingredients that help to prevent dental caries and the stripping of essential minerals from the teeth. People with xerostomia should use a fluoride containing substance (is also present in certain toothpastes or mouthwashes) regularly at least once a day. The most suitable fluoride gels contain 0.4 - 1.25 % fluoride and have a neutral base.

Tongue Cleaning:
Cleaning one's tongue is part of good oral hygiene. The back of the tongue can harbour bacteria and should therefore be regularly cleaned either by brushing the tongue with a toothbrush or using a tongue scraper. Tongue scrapers may be purchased at a chemist.

Dental Prosthesis
A dentist may create a prosthesis or "mouthguard" for an individual with xerostomia to wear at night, coating it with a fluoride gel to help protect the teeth.

Treatment Products Available From Chemists

Sialogogue mouthwashes
Sialogogue mouthwashes are mouthwashes which help to stimulate the production of the salivary glands. Glycerine and lemon mouthwashes are examples of these, however, care must be taken when using them as overuse can result in over exhaustion of the glands, further contributing to the dry mouth condition. The same thing applies for glycerine and lemon swabs often used to treat this condition. Glycerin mouthwashes or swabs are often not suggested because glycerine is an astringent, which means that it has the capability to further dry the mouth. Lemon mouthwashes contain acid and therefore may increase cavities or cause dental erosion.

Pilocarpine oral solution
Pilocarpine is a medication that can be prescribed by your doctor if appropriate. It is usually prescribed if other methods of salivary substitution do not provide relief. Pilocarpine can only be used if the salivary glands are not permanently damaged and can still be stimulated. It can be made up in an oral form, (5-10mgs), and should be taken 3 or 4 times daily, depending on the individuals response to the drug. Effects can last for approximately 2 hours, depending on the individual. Pilocarpine is not suitable for all individuals with dry mouth, particularly patients with diabetes, asthma or cardiovascular problems.

Moisturising Gels
Moisturising Gels are useful in providing relief from oral signs and symptoms associated with dry mouth. They can include preparations non-specific for dry mouth, e.g petroleum jelly, or can be bought commercially from pharmacists.9 Recommended commercially available products from pharmacists include:

Orallife Peppermint Lip Treatment
Oralbalance

Mouth Spray
This has a similar moisturizing effect as the gel, but is in a mouth spray form. It may be more convenient for people who experience difficulty manually controlling the gel. An available product in Australia is the Aquae Mouth Spray.

Saliva Substitutes
Saliva substitutes are useful when there is insufficient or no functioning glandular tissue or when other saliva promotion methods are inadequate. Saliva substitutes are necessary for chronic dry mouth, particularly for dry mouth caused by radiotherapy. Water, ice chips and atomised water sprays are good for temporary oral relief, however they do not contain any of the protective substances that normal saliva contains. A properly balanced saliva substitute product should be of neutral pH and contain electrolytes to make the composition similar to that of natural saliva, coating the mouth with a film and helping to protect the mucous membrane.

Biotene Products
Biotene products are specialised products available on the market in Australia, that help treat dry mouth. They contain salivary enzymes to help your body's natural defenses reduce the harmful bacteria and help relieve dry mouth discomfort.

Dry Mouth Toothpaste
Contains enzymes that help replenish and boost the natural antibacterial action in saliva

Gentle Mouthwash
Soothes and moistens dry and sensitive tissues of the mouth while inhibiting odor-causing bacteria

Dental chewing gum
Reduces mouth sugars and stimulates saliva flow

Moisturising gel
Relieves severe dry mouth symptoms such as burning, sore tissues, cotton palate and swallowing difficulties.

Antimicrobial or antifungal drugs
Sometimes as a result of the dry mouth, fungal infections occur in the mouth. These are referred to as oral candidiasis or oral thrush. This can result from poor oral hygiene. To treat this infection, anti-fungal drugs should be prescribed by your doctor. Anti-fungal agents can be given in lozenge form, however these may not be appropriate for certain people with dry mouth because of trauma to the inner lining of the mouth.

Alternative Treatments

Household Salivary Substitutes
It is important to consult with your doctor prior to trialing any of these treatments.

Milk appears to have many of the chemical and physical properties of a good saliva substitute. Not only does it moisten and lubricate the mouth but it is also capable of buffering acids in the mouth. 4 Margarine can be used for similar reasons.

A water-soluble extract of linseed oil has also been found to have physical properties similar to that of natural saliva and therefore can also be used to help provide relief from dry mouth.

Olive oil or vegetable oil swabbed onto the mucosa as a lubricant is also recommended as a substitute for saliva

Glandular Massage
Decreased salivary flow rates can lead to thick salivary secretions and therefore retention of saliva within the ductal system. Glandular swelling and tenderness may result. For some people, massage of the parotid and submandibular glands (refer to salivary gland diagram) can empty out the ducts, allowing the saliva to flow. However, this procedure is not suitable for all individuals with xerostomia, therefore consultation with the doctor concerning appropriateness, and how to perform the procedure is necessary prior to any action.

Acupuncture
Acupuncture stimulates the Autonomic Nervous System, which is involved in the salivation process. Acupuncture is reportedly capable of increasing parasympathetic activity, which means it increases the release of chemical reactions that stimulates salivary gland secretion. Acupuncture may not assist all individuals with xerostomia, so consult your doctor prior to any action.

Dietary Advice
You must consult your doctor, speech pathologist or dietician before any alterations to your diet are made, particularly if you have been placed on a modified diet for a specific reason.

Mastication:
Saliva secretion is often stimulated by the presence of food in the mouth. Food that doesn't require chewing results in decreased sensation and stimulation of the glands. Therefore, if possible, modifying the diet to include foods that require chewing will encourage the production of saliva.

Decreasing snacks:
Snack foods, eg. chocolates, cakes, biscuits, are often rich in carbohydrates . These foods tend to remain in the mouth, particularly if there is reduced salivary function. This increases the likelihood of bacterial accumulation and thus, infection. Additionally, foods like crackers or chips also have the potential to scrape or damage the lining of the mouth,causing bleeding, which is more vulnerable due to the decreased protective coating of the inner mouth that saliva normally produces. Additionally, a person with dry mouth should also avoid snacks high in sugar content, because this will further increase the likelihood of dental decay and gum problems.

Treating The Causes Of Dry Mouth

Sometimes it is possible to eliminate the cause of the dry mouth. For example, dehydration induced dry mouth can be treated through increasing your water intake to hydrate yourself. However, some of the causes of dry mouth, for example, auto-immune diseases like HIV or Sjogren's Syndrome cannot be eliminated and therefore treatment can only be symptomatic. The following are two common causes of dry mouth that can be targeted for treatment.

Drug Induced Dry Mouth
NB: Doctors should always be consulted prior to action concerning drugs

Elimination or Reduction of select drugs
Individuals on numerous medications should consult their doctor when suffering from oral dryness. Sometimes doctors are able to recognise that the intake of certain drugs are no longer necessary or the total intake of the specific xerogenic drugs (i.e drugs causing dryness) can be reduced.

Modification of the Drug-Intake Schedule
The higher the concentration of the drug in the blood at any one time, the more extreme the effects.
At certain times of the day a person experiences feelings of greater dryness. Therefore, a person may wish to modify the schedule of their drug intake so that the time they are taking the drug does not coincide with the time of day of their natural dryness.

Drug substitutions
Certain drugs of the same type may cause more dry mouth effects than others. Therefore, if a patient complains of one particular drug making their mouth feel dry, they should speak to their doctor or pharmacist and see if an appropriate substitute is available.

Salivary Gland Disorders

Treatment of salivary gland blockages (ie, tumours, stones, infections, inflammations) can either be medical or surgical, depending on the nature of the problem. Please consult your GP or specialist.

References

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