Xerostomia K11.7

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 31.01.2023

Synonym(s)

Aptyalisum; Asia; Asiali; Dry mouth; Oligosialia

Definition
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Dry mouth due to drying up of saliva secretion. The term "xerostomia and hyposalivation" or "oligosialia" is usually defined as subjectively perceived dryness of the oral mucosa in combination with a strong reduction of the resting saliva flow (total resting saliva flow rate: < 0.1 ml/min, stimulated total saliva flow rate: < 0.5 ml/min).

Classification
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A distinction is made between:

Normal (physiological) salivation: about 2.0 ml/min during stimulation (e.g. when chewing food); about 0.3-0.4 ml/min at rest (amount of saliva).
Restricted salivary flow (oligosialia): values between 0.5 and 2.0 ml/min. when stimulated (e.g. when chewing food); about 0.3 ml/min. at rest.
Xerostomia: values less than 0.5 or 0.2 ml/min.

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Occurrence/Epidemiology
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Frequency of 0.15%-3.8% among the North American population.

Etiopathogenesis
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Causes that can be considered are basically:
- Medication (most common cause; e.g. vitamin A acid)
- Radiological therapy in the orofacial region
- Salivary gland diseases and operations
- Diseases with salivary gland involvement
- Diseases with direct or indirect influence on the innervation and metabolism of the salivary glands
- Fluid loss due to reduced chewing activity
- Age regression (physiological).
Drug-induced xerostomia is the most common form of xerostomia in industrialized countries and in the elderly population beyond the fourth decade of life. Frequently, anticholinergics (via peripheral receptor blockade) and tricyclic antidepressants (via central receptor blockade) exert the strongest xerogenic effects. Peripheral anticholinergics (e.g., atropine) act via competitive inhibition of the glandular cell membrane acetylcholine receptor, preventing transmitter signaling. The central anticholinergics are barrier-responsive and presumably inhibit the medullary salivary center.
Other medications that can cause xerostomia:
- Antihistamines
- Antiparkinsonian drugs
- Antihypertensives
- Diuretics
- Benzodiazepines
- Sedatives
- Hypnotics
- Antihypertensives
- Cytostatic drugs.
Specific diseases of the salivary glands (e.g. malignant tumours) can lead to irreparable damage to the glandular tissue. After infections such as viral parotitis, parenchymatous fibrosis may develop as a late consequence. Narrowing or obstruction of the excretory ducts may be permanent (as in scarring stenosis) or temporary (as in salivary stones) and develop on the basis of surgical procedures, chronic infections, trauma, and tumors or, in the rare congenital malformations, are prenatally inherited.
Other diseases that can cause xerostomia:
- Sjögren's syndrome with generalized dysfunction of the exocrine glands.
- Chronic nephropathies
- Adrenal damage
- Diabetes insipidus with polyuria
- Diabetes mellitus with osmotic diuresis due to glucosuria
- Diseases with central nervous disturbances of glandular innervation in depression, psychoses and vegetative dysregulations
- Major and prolonged fluid losses (such as through blood loss, in chronic diarrhoea, in diseases with disturbances of the water balance).
- Decreased chewing activity in painful oral mucosal or dental diseases and insufficient dentures.
In accordance with the extraoral symptoms described above, the following extraoral findings may accompany xerostomia:
- Rhinitis with parosmia
- Xerophthalmia (drying up of cornea and conjunctiva)
- Keratoconjunctivitis
- Pharyngitis
- Laryngitis and bronchitis
- Reflux esophagitis
- dyspepsia.

Manifestation
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Predominantly occurring in the older population and persisting in about half of the patients suffering from rheumatic and autoimmunological (especially systemic scleroderma) diseases. Women are particularly affected after the menopause.

Clinical features
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The two cardinal oral symptoms of salivary flow reduction are a dry mouth or a feeling of roughness (tongue sticks to the roof of the mouth) and an increased feeling of thirst. Furthermore, this condition is accompanied by burning and stinging dysesthesias (tongue like raw meat), difficulty swallowing and speaking, and taste disturbances (everything tastes sticky). With impaired salivation, chewing, swallowing and speaking are difficult. The risk for oral infections also increases, especially Candida infestation.
Common subjective symptoms of xerostomia:
- Difficulty chewing (when eating dry food).
- Difficulty swallowing (when swallowing empty)
- Taste disturbances
- Speech disorders (due to adhesion of mucous membranes)
- Chewing difficulties (when eating dry food)
- Painful areas in the mouth and numbness
- Tongue burning or burning mouth
- Bad breath
- bleeding gums or tongue
- Denture intolerance.
Common extraoral symptoms of xerostomia:
- Dryness of the nasal mucosa with scabbing and nosebleeds.
- Olfactory disturbances
- Dryness of the eyes with burning of the eyes
- Dryness of the throat with hoarseness and chronic coughing
- Skin dryness
- Digestive disorders with heartburn, constipation, loss of appetite, nausea and diarrhea
- Micturition difficulties with increased urination.
Objective symptoms: In pronounced xerostomia, the lack of shine or the dull, dry surface of the oral mucosa is very noticeable. Here, not only the typical liquid lake on the floor of the mouth is missing. In this case, the oral mucosa even has the effect of a finger glide brake. Often the saliva also has a viscous and sticky consistency. Furthermore, changes in the mucosal surface with alterations of the lingual papillae, cracking or fissuring of the epithelial surface (like cracked lips or tongue), erosive and occasionally even ulcerative mucosal defects. Frequently, foetor ex ore and disturbances of the ecological balance in the biotope of the oral cavity develop with secondary bacterial, viral and mycotic (mostly candidiasis) mucosal infections.
The weakened protective function also affects the buffer capacity and remineralization ability, leads to disturbance of the hard dental tissue (progressive carious infestation) with widespread demineralization of the smooth surfaces. Teeth initially lose their shine and opaque (milky, chalky) color changes appear. The enamel loses its biomechanical properties and becomes brittle, causing rapid abrasion of the occlusal relief and incisal edges. Finally, without an adequate therapeutic concept, complete destruction of the teeth occurs.

External therapy
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The treatment is difficult, but absolutely necessary, as too little saliva can cause serious damage to the teeth. It is carried out symptomatically with increased fluid intake (mineral water, tea), saliva stimulation with chewing gum, acidic drinks, lemon-based preparations(Cave! tooth erosion in dental patients because of the reduced pH-value!) or medicinally by substitution of artificial saliva ( R236 or mouth rinses with 10-20% glycerine water).

Note(s)
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The large salivary glands of the adult human produce together about 1.0-1.5 l of saliva, of which about 77% is produced by the Gll. submandibulares and 25% by the Gll. parotides and Gll. sublinguales. The basic requirement is covered by a continuous secretion at rest. The production of saliva is subject to a circadian rhythm and decreases with age.