Dry mouth and hyposialia

Dry mouth and hyposialia

Introduction

Dry mouth is common in the general population and should be a warning sign involving etiological research based not only on questioning but also on pharmacovigilance and paraclinical explorations.

1. General:
   1. Anatomical reminder of the salivary glands:
      1. The main salivary glands:

2. Accessory Salivary Glands:

They are small glandular formations scattered under the mucosa of the entire oral cavity, except the gums and the anterior part of the bony palate.

2. Saliva:
   1. Definition :

Saliva is a watery secretion, it is produced by the three pairs of main salivary glands, namely:

• The parotid glands.
• The submandibular glands.
• The sublingual glands.

And by numerous small accessory salivary glands.

• This secretion has a liquid, colorless, tasteless, stringy appearance.
• Its role is to moisten the mucous membranes of the mouth (tongue, cheeks, pharynx) and to moisten food as well as to begin the digestion of carbohydrates (sugars).

1. The physicochemical properties of saliva:
   • The Volume:

The volume of saliva excreted daily remains uncertain and varies from one subject to another; secretion can vary from 500 to 1200 ml per day.

It is interesting to note that the secretion rate shows nycthemeral variations (minimum at 3:00 am, maximum between 12:00 pm and 10:00 pm). We can produce more than 36,000 liters of saliva in a lifetime, or more than 1/2 ton of this liquid per year.

The resting saliva secreted continuously would have a daily volume of around 100 ml, the stimulation saliva would therefore be approximately 10 times more abundant, 2/3 of it would be parotid and 1/3 submandibular.

(the production of the other glands being relatively negligible)

• Viscosity:

Saliva is physiologically transparent, it is watery for the parotids, stringy for the submaxillaries, very viscous for the sublingual and accessory glands, with the exception of the lingual VON EBNER glands which are serous.

The viscosity of the various salivas, which is clinically appreciable, is a function of the proportion of mucous cells to serous cells in the gland considered.

Viscosity varies depending on the origin:

1.5 centipoise for the parotid glands

3.4 centipoise for submaxillary 13.4 centipoise for sublingual

• The Salivary PH

Each saliva has its PH, the following figures can be considered normal: PH at the ostium of the Stenon: A: 5.5 E: 5.5

PH at Wharton’s ostium: A:6 E:6

PH on the back of the tongue: A: 6.5 -7 E: 7-7.5

The latter depends on the pH of the overall saliva, called mixed, but modified by substances called buffers which group together carbonates and proteins.

In newborns, pH levels are more acidic.

PH values ​​generally tend towards acidity at rest and towards neutrality when secretion increases.

2. Dry mouth:
   1. Terminology

1. Xerostomia: is a state of dryness of the oral cavity linked to a significant reduction or disappearance of salivary secretion, resulting from damage to all of the main and accessory salivary glands.
2. Asia: is defined as the total absence of salivary secretion.
3. Circumstances of discovery:

The practitioner may discover, through the following symptoms, hyposialia of which the patient does not complain:

• Cotton rolls removed dry from the oral cavity after prolonged care.
• Dry, red, varnished oral mucosa, sometimes covered with a whitish coating sticking to the tongue depressor.
• Dry and cracked lips, angular cheilitis may be observed.
• Examination of the salivary orifices shows little or no saliva.

* These warning signs should attract the attention of the practitioner who will specify these signs by clinical examination.

II. 3. The Clinical Examination:

It is essentially based on questioning , it looks for oral symptoms and associated extra-oral symptoms.

Oral symptoms will be carefully sought:

1. the sensation of dry mouth which we will specify:

The circumstances of appearance either progressive or sudden, following a psychological shock or a serious health problem.

2. Soft tissue pain:

Similar to itching or burning of the oral mucosa (tongue, palate, lip), this pain is sometimes accompanied by intolerance to removable or fixed prostheses.

3. Taste disorders that bother patients:

between meals saliva has an acidic or bitter taste leading to a feeling of disgust; at meal times food tastes bland; the patient may no longer tolerate acids or spices.

4. Chewing:

Most often brings relief, it is rare that the patient is led to take a semi-liquid diet.

5. Swallowing:

It can be refused outside of meals, for psychological reasons (disgust), but at meal times, swallowing does not pose any problems.

6. Phonation : it may be altered and the patient will be embarrassed to pronounce certain phonemes, this difficulty can sometimes lead the patient to exclude himself from his relationships with friends or family.

In addition to these oral symptoms, associated symptoms outside the oral cavity will be sought as part of the search for a systemic lesion:

1. ophthalmic symptoms:

Are basically a burning sensation in the eyes or a feeling of sand in the eyes when reading for a long time or watching TV.

2. ENT symptoms:

They result in a feeling of dry throat and dry nose, the prevalence of these symptoms is 70%. The patient sometimes complains of changes in his olfactory perception.

3. Chronic constipation.
4. In women, repeated vaginal fungal infections or burning sensations may occur.
5. ETIOLOGICAL DIAGNOSIS
   1. Taking medication

Is a cause of 80% of salivary deficits:

• Neuropsychotropic drugs, diuretics, antihypertensives and antiparkinsonians, and more generally all sympathomimetics.
• Anticancer drugs.
• Drug addictions are similar to drug-induced hyposialia.

2. Gougerot-Sjögren Syndrome

Is an autoimmune disease of unknown etiology, characterized by damage to the exocrine glands, particularly the lacrimal and salivary glands. The disease affects 0.2% of the population, more often women than men.

The diagnosis is generally made on the presence of 3 criteria: dry mouth, dry eyes with joint pain

3. Anti-tumor cervico-facial radiotherapy

Cervicofacial radiotherapy can cause xerostomia due to atrophy of the acini, intraglandular necrosis, fibrosis or degeneration.

Hyposialia occurs as soon as radiomucositis appears.

Damage to the salivary glands depends on the dose of irradiation and the duration of treatment.

A dose of 70 grays delivered into the salivary gland field is considered to cause an irreversible process.

4. Diabetes

Oral manifestations of diabetes are dryness of the mucous membranes causing thirst, often accompanied by taste disturbances and ketonic breath;

5. Nutritional hyposialia

Avitaminosis A, B1, B3, E, can cause dry mouth.

But it is above all the deficiency in vitamin B3 which interests the odonto-stomatologist because of the oral manifestations for which it is responsible.

Stomatitis, gingivitis, glossitis, cheilitis.

6. Xerostomia in the elderly

This sometimes almost total failure of the salivary glands is serious and irreversible. It causes dry mouth that is incompatible not only with the first stage of digestion of food by saliva, but also and above all with chewing.

The old man can no longer swallow his food and loses his strength through malnutrition.

7. Xerostomia of neurasthenia

Neurasthenia is a chronic anxious state that manifests itself through nervousness, asthenia, insomnia, headaches and various disorders that are also found in depressive states: xerostomia, ringing in the ears, burning tongue, pruritus, arthritis.

Inability to cope with physical or intellectual effort leads to a refusal to fight:

The patient gives in to his illness, feels the impossibility of getting out of it and manifests suicidal thoughts.

8. Rarer causes

1. Neurological damage: multiple sclerosis, Parkinson’s disease related to bulbar vascular neurological lesions, more precisely at the level of the floor of the 4th ventricle, sarcoidosis, non-Hodgkin’s malignant lymphoma.
2. Transient global hyposialia: for example, dry mouth during great fright.
3. smoking.
4. Alcoholism.
5. The Positive Diagnosis:

The positive diagnosis is based on:

• The interrogation:

Who tries to clarify the date of the start and the notion of temporary, recurring or chronic illness.

• The functional signs motivating the consultation, namely:

The sensation of dry mouth hindering chewing, swallowing, phonation, which leads the patient to drink and rinse the mouth often (burning sensation in the mouth), bitterness and sometimes taste disturbances.

• The inspection that should look for signs confirming dry mouth:

Alteration of the mucous membranes with dry, cracked lips, most often angular cheilitis. Smooth, depapillated, red tongues. Other mucous membranes covered with a whitish, foamy, sticky coating. Or erythematous, varnished oral mucosa, when the coating is removed.

• The expression of the salivary glands which gives little or no saliva which remains a useful gesture for the confirmation of the diagnosis in current practice.
• The sugar cube test , which, normally placed under the tip of the tongue, should melt in three minutes, and which takes much longer to dissolve in the case of dry mouth.
• Examination of the palatine mucosa, in the soft palate region, to detect and check the function of the accessory salivary glands: normally a fine sweating of the palatine mucosa appears at this location, because the orifices of the accessory glands are punctuated by fine droplets of saliva and in the case of dry mouth, this clinical sign is absent.
• The tongue depressor sticking to the tongue is also a test to suspect a salivary deficit.
• Oral pH measurement by strip on the back of the tongue; a PH meter paper shows the lowering below 6 of the pH of the mouth.
• Anatomopathological examination by biopsy of GSA +++ in Gougerot-Sjogren syndrome.

5. Treatment :

Temporary dry mouth usually resolves when the underlying infection is cleared or the medications that caused the condition are stopped. Unfortunately, if the condition is due to Sjögren’s syndrome, there is no cure for the condition.

The ideal treatment would be to remove the sialoproxenic drugs, but many of these drugs are life-threatening. Not all of them can be removed.

Outside of meals, resting salivary secretion will be stimulated by taste or mechanical elements, to obtain secretion and therefore relief for our patients.

Mechanical stimuli will be sugar-free chews, fruit pits or pieces of orange peel.

The best taste stimulant is citric acid contained in lemon juice, but its acidic character should make its use discontinuous and

Accompanied by mineral water rich in bicarbonates or followed by a mouthwash with bicarbonate.

• Saliva stimulators: Sialogogues (pilocarpine) will be prescribed to stimulate the secretion of the salivary glands and increase saliva production.
• Using artificial saliva in cases of complete absence of salivary secretion can relieve dry mouth.

Dry mouth and hyposialia

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A toothbrush replaced every three months ensures effective hygiene.
 

Dry mouth and hyposialia