Permanent dry mouth results from a decrease in the moisture content of the oral mucosa, which in most cases is associated with a reduction in the amount of saliva secreted by the salivary glands. Dry mouth is also called the term "dry mouth" (Figure 1).
Dry mouth occurs in about 10% of the population (women are most susceptible to it). If we talk only about people of retirement age, there will be more of them among patients with xerostomia - about 25% already. This is due to the fact that older people use more drugs that affect the amount of saliva production, as well as age-related deterioration of the function of the salivary glands.
Functions of saliva in the oral cavity -
Normally, an adult healthy person produces about 1.5-2.0 liters of saliva per day, which is usually ingested invisibly. Saliva is secreted by three pairs of large salivary glands - submandibular, sublingual and parotid, and enters the oral cavity through their ducts (Fig. 2). Also in the oral mucosa there are many small salivary glands, but the volume of saliva they produce is not too large.
The moisturizing effect of saliva helps protect the oral mucosa from ulcers, erosions, cracks. Saliva contains lysozyme (a bactericidal component) and antibodies, which makes it possible to effectively protect the mucosa from an infectious lesion and restrain the growth of microorganisms. Saliva has a buffer capacity that neutralizes lactic acid produced by cariogenic bacteria and thus protects teeth from caries.
Saliva contains a certain concentration of calcium ions, which are involved in the remineralization of the tooth enamel (if this were not, the teeth were completely destroyed almost immediately after eruption). In addition, saliva contributes its role in the formation of taste, contains the enzymes necessary for digesting food, chewing it and forming a food lump for swallowing. Also, saliva contributes to proper diction.
The consequences of a lack of saliva -
it is not only permanent dryness in the mouth or a violation of chewing food. The fact is that xerostomia sooner or later leads to generalized dental caries, oral candidiasis, changes in taste, bad breath (halitosis), and burning of the oral mucosa (24stoma.ru).
Severe Dry Mouth: Cause
Permanent dry mouth - what causes the disease can cause it? There are many reasons, some of them occur most often, some less. The most common cause is taking one of the following medications, for example:
1. Medication -
Some drugs have a side effect of reducing the production of saliva. Most doctors agree that xerostomia is most common in people of retirement age precisely because this group of the population is taking quite a lot of drugs. Drugs that can reduce the amount of saliva secreted -
- antihypertensive drugs
- hypoglycemic drugs
- steroid inhalers,
- tricyclic antidepressants or antipsychotics,
- diuretic drugs,
- NSAIDs (nonsteroidal anti-inflammatory drugs),
- multivitamins and supplements
2. Systemic diseases and conditions -
If you have a very dry mouth for a long time, the reasons may be due to one or several chronic diseases. Many of these diseases are difficult to diagnose, plus the quality of Russian medicine is so low that it is unlikely that the dentist to whom you will come will look for the true cause of xerostomia (if, of course, this is not a simple reason lying on the surface).
That is why many patients with xerostomia - its cause remains unknown, and as a diagnosis they write in the map: "Xerostomia of unknown etiology." For such diseases, it is best to contact clinics at the dental faculties of medical universities (the department of surgical dentistry). In this case, the chance for diagnosis and quality treatment will be higher. In Moscow, for example, in addition, you can also contact the ZNIIS.
Xerostomia may cause:
- Endocrine Diseases -
in patients with diabetes mellitus type 1-2, with autoimmune thyroid disease (observed in 5-15% of women, as well as in 1-5% of men).
- Autoimmune Diseases -
rheumatoid arthritis, Sjogren's syndrome / disease, systemic lupus erythematosus, primary biliary cirrhosis, scleroderma.
- Viral diseases -
Epstein-Barr virus, cytomegalovirus, human T-lymphotropic virus type 1, and hepatitis C virus.
- Bacterial infections -
- Granulomatous diseases -
sarcoidosis (disease of unknown etiology), tuberculosis.
- After radiation therapy of head and neck cancers.
3. Other possible causes -
Below we list the simplest causes, which can also cause constant dryness of the oral cavity. Most of these causes are easily treatable (unless, of course, you are pregnant), and in most cases you do not even have to consult a doctor.
- mouth breathing (nasal congestion),
- frequent use of mouthwash containing alcohol,
- malnutrition, fasting or anorexia (lack of appetite),
- dry mouth during pregnancy (associated with hormonal imbalances),
- depression, anxiety, stress,
- excess caffeine intake,
- with iron deficiency in the body.
4. Dry mouth in the morning or at night -
Dry mouth in the morning or patient complaints of dry mouth at night - the reasons for this are related to oral breathing (usually due to nasal congestion). The fact is that at night the salivary glands secrete significantly less saliva than in the daytime. When breathing through the mouth, moisture from the mucous membrane of the oral cavity rapidly evaporates, and the volume of saliva secreted at night cannot compensate for it. The main treatment will be directed to the restoration of nasal breathing, and if this is connected with the curvature of the nasal septum, surgical intervention will be required here.
Dry mouth: symptoms of the disease
Patient Complaints -
patients with xerostomia often complain about the constant dryness of the mouth and lips, burning of the tongue and mucous membrane of the mouth, bitter taste in the mouth, and also constantly feeling thirsty, bad breath, uncomfortable chewing and ingestion of food, disturbance sensations of taste and smell.
In patients with removable dentures - complaints are added about the inability to use dentures due to severe pain. Some patients also complain of problems with diction and persistent cough.
When viewed from the mouth -
- dry lips
- pale or bright red thinned mucous membrane,
- lack of saliva in the mouth (or a small amount of frothy saliva),
- dry folded tongue with atrophied filiform papillae,
- tongue is covered with white bloom
- there is an unpleasant smell from the mouth.
Also, when examining the entire oral cavity, as a rule, visualized: abundant microbial plaque on the teeth, fungal infection of the mucous membrane (oral candidiasis), various erosions and ulcers, poorly healing traumatic injuries, multiple caries and gum inflammation. All this is associated with reduced local immunity of the oral mucosa, as well as with a large number of pathogenic microflora.
How to make a correct diagnosis?
The rate of salivation stimulated during eating is normally 1.5-2.0 ml / min, while the rate of release of unstimulated saliva is approximately 0.3-0.4 ml / min. The term "hyposalivation" means a decrease in the functional activity of the salivary glands. Such a diagnosis is made when the rate of stimulated salivation is less than 0.5-0.7 ml / min, and the rate of unstimulated salivation is less than 0.1 ml / min.
The diagnosis of "xerostomia" in patients with hypo-salivation is made when the volume of secreted saliva becomes less than the rate of absorption of fluid through the mucous membrane of the oral cavity + the rate of evaporation of fluid in the oral cavity (during a conversation or breathing).
Where to go -
You will need to contact a dental surgeon who will have to check the functioning of the salivary glands (massage them and see if the saliva is released from the ducts and in what quantity). Also, the inspection will reveal the presence of stones in the ducts of the salivary glands, which can impede the secretion of saliva. An assessment of the transparency of secreted saliva can tell about the presence or absence of possible infectious inflammation in the tissues of the salivary glands.
It is best to seek such advice from maxillofacial surgeons from the hospital, and not to outpatient dental surgeons from the clinic, because the latter are clearly not enough experience to treat this pathology. In addition, if a stone is found in the duct or inflammation of the tissues of the salivary glands, the maxillofacial surgeon will be able to treat more effectively.
As we have said above, it is best to immediately go to clinics at a medical university, where there is a department of surgical dentistry. Associate professors and professors conduct reception and consultations there, they teach dental students and are engaged in scientific work, and therefore all complex cases of xerostomia are exactly there. Well, if you live in Moscow or the Moscow region - you can still contact the State Clinic ZNIIS (Central Research Institute of Dentistry).
Dry mouth treatment -
The main treatment should be aimed at eliminating the causes of dry mouth. For example, if the cause was inflammation of the salivary glands or a stone in the duct of the salivary gland, you need to contact a dental surgeon and treat inflammation, remove the stone from the duct. In case of oral breathing, it is necessary to contact an ENT specialist and treat diseases of the nose. When using rinses with alcohol - it is necessary to stop their use. But these are all fairly simple cases, the cause of which is easily diagnosed and quite easily eliminated.
In difficult cases, such as with Sjogren syndrome or after radiotherapy of the head and neck area, it is important to choose the right treatment strategy. Under these conditions, the correct option would be to assign a means to stimulate the function of the large salivary glands. However, such means work only when the parenchyma of the salivary glands (glandular tissue, which secretes saliva) is at least partially preserved. If sclerosis of the parenchyma occurred as a result of an infectious or autoimmune process, then there is simply nothing to stimulate.
In these cases, you can only try to stimulate the function of the small salivary glands with physostigmine + and assign artificial substitutes for saliva in the form of gels and rinses (we will discuss this later). If xerostomia occurs as a result of medication, the best results are observed after the local stimulants of salivation are prescribed in the form of a mouth spray with malic acid + dose adjustment of the drug or its replacement by another.
The treatment of xerostomia is made up of -
- stimulation of the function of the salivary glands,
- artificial moistening of the mucous,
- nutritional supplements,
- prevention of caries, inflammation of the gums, oral candidiasis.
1. Medical stimulation of salivation -
Systemic stimulation of salivation can be achieved through the use of 2 approved drugs. The first drug is Pilocarpine (pilocarpine), which is a alkaloid of plant origin. This drug also has the ability to stimulate the function of the salivary glands. Depending on the severity of the disease, pilocarpine may be administered 3 or 4 times a day, 3 or 5 mg for at least 3 months.
The second drug is Cevimeline Hydrochloride (cevimeline hydrochloride). This is a cholinergic agent, which has a regimen of 3 times a day, 30 mg each - also for at least 3 months. However, the majority of clinicians still prefer pilocarpine, both in case of Sjogren's disease and after radiation therapy. But these drugs will be effective only if the salivary gland parenchyma is at least partially preserved!
Important: Pilocarpine and cevimeline are relatively contraindicated in patients with uncontrolled asthma or chronic lung disease in patients taking β-blockers. They should also be used with caution in patients with peptic ulcer of the stomach and intestines, and in patients with uncontrolled hypertension. In addition, pilocarpine is contraindicated in patients with narrow-angle glaucoma, with caution in cardiovascular diseases.
Stimulation of the small salivary glands -
If the above drugs are aimed at stimulating the function of the large salivary glands, then the drug Physostigmine is capable of stimulating the smallest salivary glands evenly distributed throughout the oral mucosa. This drug belongs to cholinomimetics, causing blockade of the enzyme acetylcholinesterase. Clinical studies have shown that most patients with xerostomia praised its effectiveness.
The daily dosage of physostigmine is usually 1.8 mg. This drug can be effective even with sclerosis of the parenchyma of the major salivary glands, while it does not have significant side effects in this dosage.
2. Artificial hydration of the oral mucosa -
In this section, we describe the means for local application in the oral cavity, recommended for the treatment of xerostomia. These include salivation stimulants and saliva substitutes.
Salivary stimulants -
Clinical studies have shown that one of the most effective local saliva stimulants is a spray based on 1% malic acid. One of them is Dentaid Xeros spray (Dentaid Xeros). However, due to acid, they can cause moderate erosion of enamel. Therefore, it is important that the composition of the spray were fluoride compounds + xylitol, allowing you to make tooth enamel more resistant to acid. Against the background of this treatment, patients are recommended to use therapeutic toothpastes with a high content of fluoride.
Chewing gum -
it can also help stimulate salivation, but it is important to remember that you cannot use chewing gum or lozenges that contain sugar (otherwise multiple caries is guaranteed). Help in stimulating salivation can also be - peppermint extract, drops with lemon juice, as well as bitter herbs tincture. But the simplest home remedy is to drink as little as possible a small amount of water throughout the day, especially while eating.
Saliva substitutes -
In addition to chewing gum, there are also special substitutes for saliva, the use of which makes it possible to imitate the presence of natural saliva in the oral cavity. For this purpose, special solutions and sprays are used, which will contain any combination of the following components - carboxymethylcellulose or hydroxyethylcellulose, olive oil, glycerin, and additional components - betaine, allantoin, xylitol, fluorine, calcium or phosphates.
Clinical studies have shown that when it comes to saliva substitutes, gel forms are the most effective. And we are talking not only about the products that are produced in the form of gels, but also those that take on a gel form already in the oral cavity. For example, tablets of anhydrous crystalline maltose also reduce the symptoms of xerostomia (in the oral cavity, they turn into a gel lining the mucous membrane, that is, in fact, also act as a substitute for saliva).
Examples of products for patients with xerostomia -
Below you will find remedies for patients with xerostomia available in Russian pharmacies and online stores. In fact, we can name only two manufacturers. This means the Spanish manufacturer "Dentaid" (can be found in the pharmacy, often under the order, as well as in online stores), as well as funds under the brand "Biotene" American-made, which are sold only in online stores.
1) Spray "Dentaid Xeros" (15 ml) -
- producer - Spain,
- active substances - 1% malic acid, sodium fluoride, xylitol,
- the price for a tube of 15 ml - from 220 rubles.
Comments: in contrast to the previous tool, which is an artificial substitute for saliva, Dentaid Xeros spray is designed specifically to stimulate salivation (due to the content of 1% malic acid). In addition, this spray has fluoride and xylitol, which strengthen tooth enamel, thereby reducing the risk of erosion of the tooth enamel from acids. Good composition, great price.
2) Gel "Biotene Oral balance" -
- Manufacturer - USA,
- active substances - starch hydrolyzate, hydroxyethylcellulose, lysozyme, xylitol, dairy enzyme complex (lactoperoxidase, lactoferin, glucose oxidase), aloe extract,
- The price for a tube of 42 g is about 1200 rubles.
Comments: this gel is an expensive tool, although in the US its price is only $ 6. Its main components are starch hydrolyzate and hydroxyethyl cellulose, which line the oral mucosa.However, the gel also contains the enzyme saliva lysozyme + a large number of dairy enzymes that increase the local immunity of the mucous membrane, protecting it from damage, stomatitis, oral candidiasis.
This product also has a spray form (tube 44 ml at a price of 1200 rubles), as well as mouth rinse - at a price of 1600 rubles per tube 470 ml. However, clinical trials assessing the effectiveness of "Biotene Oral Balance" are more disappointing. In the study of the authors "Gil Montoya et al." (2008) it was tested against placebo. The researchers, evaluating the symptoms of dry mouth, concluded that there were no significant differences between these groups.
3) Dentaid Xeros Gel (500 ml) -
- producer - Spain,
- active substances - glycerin, hydroxyethyl cellulose, betaine, aloe vera, xylitol, sodium fluoride,
- does not contain alcohol,
- 50 ml tube - price from 270 rubles.
Comments: quite effective and inexpensive gel from the company Dentaid (Spain). This is a substitute for saliva based on glycerol, betaine and hydroxyethyl cellulose, which is applied to the oral mucosa with a finger (as needed). Allows you to protect the mucosa from drying out, and due to the content of xylitol and fluorine - strengthens tooth enamel.
4) Rinse "Dentaid Xeros" (500 ml) -
- producer - Spain,
- active substances: glycerin and hydroxyethyl cellulose, as well as additional components - allantoin 0.1%, betaine 1.33%, xylitol 3.3%, sodium fluoride (226 ppm),
- does not contain alcohol,
- 500 ml - the price of 290 rubles.
Comments: Dentaid Xeros rinse is a saliva substitute, which, after rinsing the oral cavity, leaves on the mucous membrane a layer consisting of compounds of glycerol, hydroxyethylcellulose and betaine. This layer retains moisture and protects the mucosa from drying out. Contains an additional anti-inflammatory component allantoin, as well as fluoride and xylitol to strengthen the teeth.
5) Tools for cleaning teeth -
The choice of oral care products for patients with xerostomia in Russia is very limited. As a matter of fact, only special toothpaste from the "Dentaid Xeros" series - based on glycerin, betaine, allantoin, 1450 ppm sodium fluoride, and xylitol can be attributed to special toothpastes. Its price is quite reasonable - only from 270 rubles, although in some stores it is sold at 400 rubles.
Toothpaste from the series of products "Dentaid Xeros" -
Or you can call the toothpaste brand "Biotene" from the United States, which in Russia is sold at a price of 1600 rubles, although in the United States its red price is only $ 5.5. The beauty of this paste lies in the content of a complex of dairy enzymes and lysozyme, as well as fluoride (24stoma.ru). However, similar pastes with dairy enzymes and lysozyme can be found in Splat toothpastes, costing only 130-170 rubles.
3. Influence of food additives -
As a doctor, I do not really trust food additives. However, there are authoritative clinical studies that confirm the positive effect of Omega-3, vitamin E, and wheat germ oil on the dryness of the oral cavity in Sjogren's disease. Clinical study - Singh M, Stark PC, Palmer CA, Gilbard JP, Papas AS (published in the professional medical journal "Spec Care Dentist", in 2010).
By the way, in patients who received psychotropic drugs (tricyclic antidepressants or neuroleptics) and suffered from xerostomia - the drug Yohimbine, also a dietary supplement, showed good results in stimulating salivation. This effect has also been confirmed in studies.
4. Prevention of caries and candidiasis -
It is very important! The lack of saliva stimulates the growth of microbial plaque, therefore, patients with xerostomia in the mouth, as a rule, always have a soft microbial plaque, hard dental deposits. This creates prerequisites for the development of multiple caries, inflammation of the gums, oral candidiasis (oral thrush). Moreover, in patients with xerostomia these diseases occur much faster than in patients without xerostomia, and they also proceed more unfavorably.
To prevent this, proper oral hygiene is necessary, which must always be carried out after each meal. In this case, it is necessary to use not only a toothbrush and paste, but also a dental floss. It is very important to avoid snacking between main meals (chips, candy, cookies), and also to avoid sugary carbonated drinks, sugar-containing juices. The correct technique of using dental floss and brush - look at the video.
How to use floss and toothbrush -
→ Detailed rules for hygiene and teeth cleaning
Important: We have already spoken several times before that it is very important to protect the mucous membrane with the help of a complex of dairy enzymes and lysozyme (an enzyme of saliva that has an antibacterial effect). These substances increase the local immunity of the mucous membrane. This will protect you from oral candidiasis, stomatitis and other diseases of the oral mucosa.
How effective can the treatment be?
Treatment of xerostomia is very difficult in patients with autoimmune processes (such as Sjogren's disease, rheumatoid arthritis, systemic lupus erythematosus), as well as in patients undergoing radiation therapy of the head and neck. Pilocarpine in these cases is the main therapeutic agent. Studies have shown that the use of Rebamipide or malic acid sprays does not improve these patients (compared with the placebo group).
The use of Rituximab (monoclonal antibodies) in such patients gives a good result of treatment only for lymphoma and rheumatoid arthritis. However, according to clinical studies, in case of Sjogren's disease, this drug no longer shows significant efficacy compared with placebo. We hope that our article on the topic: Dryness in the mouth, cause and treatment - turned out to be useful to you!
Author: dentist Kamensky K.V., 19 years experience.