This document discusses xerostomia (dry mouth), including its definition, causes, diagnostic approach, and management considerations. Xerostomia can be caused by salivary gland disorders, medications, head/neck radiation, and various systemic conditions. The diagnostic approach involves assessing the patient's medical history and symptoms, performing oral examinations and tests of salivary flow rates, and determining whether further workup is needed. Proper diagnosis of xerostomia's underlying cause is important to institute effective management and prevent oral health complications.
3. XEROSTOMIAXEROSTOMIA
Defined as a subjective complaint of oral dryness
that may result from a decrease in the production
of saliva; encompasses spectrum of oral complaints
Most common presentation of salivary gland disease;
but not always associated with salivary gland
hypofunction
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7. SYSTEMIC CONDITIONS THAT MAY HAVE
XEROSTOMIA AS A SYMPTOM
Endocrine
Diabetes
Hyper & hypothyroidism
Addison’s disease
Cushing’s syndrome
Malnutrition
Eating disorders
Anorexia nervosa
Anemia
Alcohol abuse
Atrophic gastritis
Autoimmune
Granulomatous diseases
GVHD/Bone marrow transplantation
HIV/AIDS
Others
Liver disease Renal dialysis
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8. CONSIDERATIONSCONSIDERATIONS
Some patients who complain of dry mouth do not
have evidence of reduced salivary flow
Patients with salivary dysfunction rarely complain
of oral dryness as a solitary symptom
Wide range of flow rates fall within the normal
physiological range - hence difficult to substantiate
salivary gland hypofunction in patients who complain
of xerostomia
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9. Chief Complaint (symptomatic / asymptomatic)
Dry mouth questionnaire
Medical history and review of systems
Yes No
Clinical evaluation
Yes
Further diagnostic work up
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10. Questions that help identify people with or at risk of
developing salivary gland hypofunction
1. Does the amount of saliva in your mouth seem to be too
little? Too much? Or you do not notice it?
An ‘yes’ response to this question is an indication of reduced
unstimulated saliva
2. Do you have any difficulties in swallowing?
3. Does your mouth feel dry when eating a meal?
4. Do you sip liquids to aid in swallowing dry food?
An ‘yes’ response to these indicates reduced stimulated saliva
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11. SYMPTOMATIC PATIENTSSYMPTOMATIC PATIENTS
Onset
Frequency, duration
Severity
Dry mouth
Hoarse voice
Trouble while eating, speaking, swallowing & chewing
Frequent need to sip water while eating dry food
Awakening at night with oral dryness
Loss of taste acuity
Oral pain, Stomatodynia
Sensitivity to spicy or coarse food
Denture discomfort
Dry/irritated eyes
Dryness of the skin
& vagina
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12. CLINICAL EVALUATION
Tongue blade test:
To assess tissue dryness.
.
General
PhysicalPhysical
EmotionalEmotional
Soft tissue examination
Desiccated and friable
Erythematous
Cobblestoned / fissured tongue
Atrophy of filiform papillae
Candidiasis
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13. Salivary gland evaluation
Enlargement
Tenderness on palpation
Lack of saliva flow on palpation
Blood /pus in saliva on palpation
Atrophic salivary ducts
Hard tissue examination
Primary & secondary caries
Cervical / Root surface caries in elderly
New & recurrent carious lesions
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15. Sialometric Evaluation
Saliva collection
Stimulated saliva flow rates
of <0.7mL/min considered abnormally low.
Unstimulated saliva flow rate
of <0.1mL/min
FactorsFactors
Patient positionPatient position
HydrationHydration
Diurnal/ seasonal variationDiurnal/ seasonal variation
TimeTime
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16. ORAL SCHIRMER’S TEST
Based on measurement of
wetted length of filter
paper strip
WAFER TEST
Based on Time of
dissolution of wafer
measured from the
moment when the wafer is
put upto the time when the
wafer dissolves
SALIVARY FERNING TEST
Ferning phenomenon
based on uniformity,
branching , spreading &
integrity of arborization [ferns]
SAXON TEST
involves chewing on folded ,sterile
sponge for 2 minutes. Saliva
production is quantified by
weighing the sponge before and
after chewing
Type I Type II Type III Type IV
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18. PSYCOLOGICAL AND NEUROLOGICAL CONDITIONS
Xerostomia occurs during periods of acute anxiety, depression
and stress owing to predominant sympathetic stimulation
during such periods which causes sparser and more viscous
salivary flow
Assessment of depression
– Beck Depression Inventory Swedish version of revised 21
item focuses on affective, cognitive, somatic and
behavioral aspects of depression
Assessment of Anxiety
– State-Trait Anxiety Inventory
Assessment of stress
– General Perceived stress questionnaire- emphasizes
cognitive perceptions more than emotional states or
specific life events
[ Source :J of Psychosomatic Research 37: 19-32]
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20. XEROSTOMIA DUE TO NEUROLOGICAL
CONDITIONS
Major depressive disorder
• Chief complaint: chronic facial pain,Chief complaint: chronic facial pain,
burning sensation of the oralburning sensation of the oral
mucosa[often on the tongue] or TMJmucosa[often on the tongue] or TMJ
disorderdisorder
• Other oral signs of dry mouthOther oral signs of dry mouth
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21. MDD contd…MDD contd…
DDysphoriaysphoria
AnhedoniaAnhedonia
IInsomniansomnia
PPsychomotor retardationsychomotor retardation
SSomatic complaintsomatic complaints
SSocial withdrawalocial withdrawal
Substance abuseSubstance abuse
Weight loss/gainWeight loss/gain
Rise in circulatory cortisolRise in circulatory cortisol
levelslevels
Neuroimaging studiesNeuroimaging studies
a. Abnormalities in blood flowa. Abnormalities in blood flow
b. Abnormalities in glucoseb. Abnormalities in glucose
metabolism in limbic systemmetabolism in limbic system
and amygdalaand amygdala
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22. ALZHIEMER’S DISEASE
Characteristic features
– Reduced ability to perform activities of daily living
– Loss of memory
– Apraxia : inability to perform certain acts or
movements; can be tested by asking the patient to
use objects or to make or initiate certain movement
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23. Assessment of aphasia
Formal analysis
Speech defects can be analyzed
Assessment of spoken speech
Paraphasia, neologisms, articulatory disturbances, orofacial apraxia,
speech repetition
Assessment of written language
Reading test
Writing test
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24. INVESTIGATIONS [of dementia in general]
Imaging of head-
– CT/MRI: CT scan reveals diffuse atrophy of cerebral cortex,
wide sulci and dilated ventricles
Blood tests
– Full blood count, ESR
– Urea and electrolytes, glucose
– Calcium, LFTs
– Thyroid function tests
– Vitamin B 12 assay
– VDRL test
– ANA, anti-ds DNA
Chest radiograph
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25. Xerostomia in patients with diabetes/suspected
diabetes
Medical & oral health history
Dental examination- caries, periodontal assessment
Assessment of salivary function
– Subjective assessment
– Objective assessment- salivary flow rates
Taste assessment
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26. Assessment of diabetes complications
– Glycemic control: Elevated glycosylated Hb
levels is associated with greater progression of
hyposalivation
– Nephropathy
Urinary albumin- 200gm/min in 2 of 3, timed
urine samples
Serum creatinine - >180 mol/L
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30. HIV ASSOCIATED XEROSTOMIA
Neoplastic & non-neoplastic lesions occur in salivary
glands
Benign [unilateral/bilateral] enlargement of salivary
glands
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31. –
Stimulated salivary flow rates
– Eye examination- for kerato-conjunctivitis
sicca
– Serology – for anti-nuclear antibodies,
rhematoid factor, SS-A &SS-B antibodies–
these are absent in HIV
– Sialochemistry :increased albumin &
borderline increase of IgA ,protein & lysozyme
– CT: multicentric cysts/larger cysts ranging
from0.5-4 cm in diameter
– MRI
– Ultrasound
– FNA/BIOPSY
Diagnostic procedures
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32. Diagnosis in Xerostomia in Chronic GVHD
Clinical features
Skin changes
Sialometric Analysis
Sialochemistry
– Higher salivary concentration of sodium,
epithelial growth factor, total protein, albumin
and IgG
– Decreased concentration of IgA
Biopsy :expression of adhesion molecules on
the salivary ductal epithelial cells[VCAM-1] is
more profound in GVHD
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33. Xerostomia in Granulomatous conditions
TUBERCULOSIS
Salivary gland swelling,
granuloma/cyst formation
within the salivary glands
PCR based salivary assays
to detect mycobacterium
tuberculosis
Salivary tests for diagnosis
of tuberculosis
Cultures
SARCOIDOSIS
Bilateral, painless, firm
salivary gland enlargement
Heerfordt’s syndrome-
Uveitis
Facial palsy
Parotid swelling
Histopathology– classic
non-caseating granulomas
Serum chemistry-calcium
level, autoimmune
serologies increased
angiotensin-1 converting
enzyme concentration
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34. Xerostomia in nutritional deficiencyXerostomia in nutritional deficiency
disordersdisorders
Anorexia Nervosa
HHistory
Salivary gland enlargement
Total and salivary specific amylase levels
Eating disorders
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35. Alcohol abuse
Acute alcohol consumption-
Diagnosis
- Enhanced output of total protein & amylase
- Decrease in the output of electrolytes
Chronic alcoholism
Diagnosis
– Fatty tissue changes
– Acinar hypertrophy, Accumulation
of secretory granules
– Enlargement of lumen within
the ductal system
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36. Clinical manifestations
– Sialadenitis
– Chronic major salivary gland enlargement
– Absence of symptoms of dry eyes
Histopathology
Salivary gland imaging – CT, MRI and ultra sound
scan
Detection of HCV DNA in the saliva
Serologic detection of anti- HCV antibodies and HCV
DNA
Xerostomia in HCV Infection
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37. Conclusion
It is important to recognize that, xerostomia is not a
diagnosis, but a symptom with various possible
causes. Diagnosis of the underlying systemic cause
is the need of the hour
The series of steps described in this paper enhance
dentist's ability for early detection of salivary gland
hypofunction in both with or without dry mouth.
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38. As Oral Physicians, in an attempt to lower the
incidence of devastating effects on oral health, and
institute appropriate management, we can diagnose
the possible cause of Xerostomia in a timely manner
and ultimately enhance the quality of life.
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