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Saturday, August 23, 2025

Dry mouth


Introduction

Dry mouth, or xerostomia, is defined as the subjective feeling of oral dryness, usually due to salivary gland hypofunction. Saliva plays a critical role in lubrication, digestion, taste, oral mucosal protection, antimicrobial activity, and tooth remineralization.

Persistent dry mouth increases risk of dental caries, gum disease, oral candidiasis, dysphagia, halitosis, and impaired speech. It may be a side effect of medication, a sign of systemic disease, or a consequence of radiotherapy.

Physiology of Saliva

  • Produced by major salivary glands (parotid, submandibular, sublingual) and minor glands.

  • Composition: 99% water, plus electrolytes, enzymes (amylase), mucins, immunoglobulins.

  • Controlled by autonomic nervous system (parasympathetic > sympathetic).

Causes of Dry Mouth

1. Medications (Most Common Cause)

  • Anticholinergics (atropine, oxybutynin).

  • Antihistamines (diphenhydramine, loratadine).

  • Antidepressants (SSRIs, TCAs, MAOIs).

  • Antipsychotics.

  • Antihypertensives (clonidine, diuretics, beta-blockers).

  • Opioids, benzodiazepines.

  • Cancer chemotherapy agents.

2. Systemic Diseases

  • Sjögren’s syndrome (autoimmune): Destruction of salivary and lacrimal glands.

  • Diabetes mellitus, poorly controlled.

  • Thyroid disorders.

  • Parkinson’s disease.

  • Depression, anxiety.

3. Local Factors

  • Salivary gland infection or obstruction (sialadenitis, stones).

  • Mouth breathing, nasal obstruction, sleep apnea.

  • Smoking, alcohol use, dehydration.

4. Iatrogenic Causes

  • Head and neck radiotherapy: Irreversible gland damage.

  • Surgery: Salivary gland removal or duct damage.

Clinical Features

  • Symptoms: Dryness, sticky saliva, difficulty speaking/swallowing, altered taste, burning sensation, halitosis, nocturnal thirst.

  • Signs:

    • Dry, erythematous oral mucosa.

    • Fissured tongue, angular cheilitis.

    • Increased dental caries, periodontal disease.

    • Oral candidiasis (white patches).

  • Severe cases: Dysphagia, malnutrition, recurrent infections.

Diagnostic Approach

1. History

  • Drug history (polypharmacy is major cause).

  • Systemic disease history (autoimmune, endocrine).

  • Radiation exposure.

  • Onset, duration, severity.

2. Physical Examination

  • Inspect oral mucosa, salivary gland swelling/tenderness.

  • Assess dentition and oral hygiene.

3. Investigations

  • Sialometry: Measures salivary flow rate.

  • Autoimmune tests (if Sjögren’s suspected): Anti-Ro/SSA, Anti-La/SSB antibodies, ANA, RF.

  • Blood glucose/HbA1c: Diabetes.

  • Thyroid function tests.

  • Imaging: Ultrasound, sialography, MRI for obstruction.

  • Labial salivary gland biopsy: Diagnostic for Sjögren’s syndrome.

Management and Treatment

Treatment depends on cause, severity, and complications.

A. General Lifestyle and Supportive Measures

  • Frequent sips of water.

  • Sugar-free gum or lozenges to stimulate saliva.

  • Avoid caffeine, alcohol, smoking.

  • Use humidifier at night.

  • Strict oral hygiene; regular dental visits.

B. Pharmacological Treatment

1. Saliva Substitutes

  • Artificial saliva sprays or gels (carboxymethylcellulose, hydroxyethylcellulose).

  • Used as needed for relief.

2. Saliva Stimulants (Sialogogues)

  • Pilocarpine: 5 mg orally three times daily.

  • Cevimeline: 30 mg orally three times daily.

    • Effective in Sjögren’s and post-radiation xerostomia.

    • Contraindicated in uncontrolled asthma, glaucoma, cardiac arrhythmias.

3. Topical Antifungals (for oral candidiasis if present)

  • Nystatin oral suspension (100,000 units/mL): 5 mL swish and swallow four times daily for 7–14 days.

  • Clotrimazole troches 10 mg: Dissolve in mouth five times daily.

4. Fluoride Therapy

  • Daily fluoride toothpaste or gels to prevent dental caries.

  • Sodium fluoride 1.1% gel applied nightly.

5. Treating Underlying Disorders

  • Diabetes: Glycemic control (metformin 500 mg orally twice daily, insulin as required).

  • Sjögren’s syndrome: Hydroxychloroquine 200 mg orally once daily, immunosuppressants if systemic.

  • Thyroid disorders: Levothyroxine replacement (25–100 mcg orally daily, titrated).

C. Dental and Oral Care

  • Regular dental check-ups every 3–6 months.

  • Professional cleaning to prevent caries and periodontal disease.

  • Fluoride varnish applications.

D. Radiotherapy-Induced Xerostomia

  • Amifostine (cytoprotective): 200 mg/m² IV prior to radiation (protects glands).

  • Pilocarpine or cevimeline if glands partially functional.

  • Saliva substitutes for persistent dryness.

Complications

  • Increased dental caries and tooth loss.

  • Periodontal disease.

  • Oral candidiasis.

  • Difficulty in speech and swallowing → malnutrition.

  • Aspiration pneumonia (from poor clearance).

Prognosis

  • Drug-induced xerostomia: Improves if medication adjusted.

  • Sjögren’s syndrome: Chronic, progressive, managed symptomatically.

  • Radiation-induced: Often permanent, but manageable.

  • Metabolic/endocrine causes: Improve with control of underlying disease.

Patient Education

  • Importance of hydration and oral hygiene.

  • Avoid sugary snacks/drinks.

  • Use saliva substitutes before meals and at night.

  • Seek early dental and medical care if ulcers, infections, or worsening dryness.




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