Dry mouth and hyposialia
I. Introduction:
Saliva is a biological fluid secreted by the salivary glands inside the oral cavity.
There are 2 types of salivary glands:
Main: parotid, submaxillary, sublingual.
Accessories: lingual, labial, velar, palatal, and jugal.
It plays many roles: humidification, lubrication, cleansing and protection.
II. Definitions:
1. Hyposialia: Hyposialia is the decrease in salivary production and secretion.
2. Asialie: “ptyalism”: The total absence of saliva secretion.
3. Xerostomia: Xerostomia defines the state of dryness of the oral cavity and the various mucous membranes bordering it, felt and described subjectively by the patient, reflecting a direct or indirect attack on the salivary glands which manifests itself either by a reduction in salivary flow “hyposialia” or by zero salivary secretion “asialia”.
III. Aging of salivation:
See course “Aging of functions”.
IV. Etiopathogenesis of hyposialia in the elderly:
Progressive atrophy of the salivary parenchyma, aging of the autonomic nervous system and poverty in immune components (salivary IgA) are the main characteristics of the alteration of salivation function in the elderly, with the direct consequence: a modification of salivary quantity “hyposialia”, inseparable from the modification of salivary quality.
The saliva of the elderly is therefore rarer and thicker.
The onset and amplitude of hyposialia can be aggravated by the presence of numerous risk factors such as: smoking and other addictions, but also general pathologies and/or their treatments.
The most common examples are:
- Diabetes:
Hyperglycemia promotes, through osmolar phenomena, the retention of water in the blood compartment. The saliva produced is more rich in glucose, maximizing the risk of caries.
- Grougerot-Sjögren syndrome:
Combining xerostomia, xerophthalmia and autoimmune diseases, the most common being rheumatoid arthritis
- Cervicofacial radiotherapy;
4. Taking sialoprive medications:
Many drugs have effects on saliva production. The first class to be incriminated is that of antidepressants and other sleeping pills.
Other medications may also be implicated: antihypertensives, beta-blockers, diuretics, antiarrhythmics, and antihistamines.
Since elderly patients often have multiple prescriptions at the same time, the effects can accumulate and cause severe hyposialia, even asialia.
5. Edentulation and lack of compensation:
Tooth loss and lack of compensation, or by wearing an inadequate prosthesis also find their place in this context. Indeed, chewing promotes salivation.
Toothlessness leads to a soft, non-cleansing diet.
The lack of dentoalveolar stimulation contributes to the atrophy of periodontal structures and tooth loss.
6. Other factors:
In addition, the tongue can no longer properly ensure the circulation of the food bolus, itself made less mobile by the lack of lubrication, which makes the situation worse. Thus, friction against the different mucous membranes is reduced, aggravating the hyposialia.
V. Semiology of hyposialia:
Alterations in salivation in the elderly may present several signs:
Subjective signs:
- Need to drink often, to suck food;
- Sensation of dry mouth, labial;
- Difficult eating
- Difficulty speaking
- Mucosal pain
- Metallic taste
- Halitosis
- Wearing a prosthesis is uncomfortable and painful
Sign objectives:
- A salivary flow rate of 0.1 ml/min
- Red, dry, varnished mucous membranes
- Tongue stripped, varnished, sticking to the mucous membranes.
Dry mouth and hyposialia
VI. Consequences of hyposialia:
Lack of saliva will have many repercussions:
- Oral discomfort (tingling or burning sensations, dryness, pasty mouth);
- Halitosis;
- Appearance and development of caries and other mucosal lesions;
- Worsening of periodontal disease;
- Development of candidiasis;
- Less good hold of the prostheses (loss of suction effect, saliva pumping by the resin)
- Establishment of a soft diet (harmful to oral and general health).
VII. Diagnosis of hyposialia:
Since the manifestations and consequences of hyposialia are significant, it is essential to detect it and correctly estimate its extent.
In addition to collecting the signs mentioned above, some authors suggest using visual numerical scales, which are similar to those used to describe pain, to help patients describe their discomfort.
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There are other ways that can highlight it:
- Measuring saliva flow:
The patient is relaxed, in a sitting position. After swallowing, a period of 5 minutes is counted and during which the unstimulated saliva will accumulate in the oral cavity will be passively collected in a sterile graduated cup, allowing the salivary flow to be measured.
A value of 0.3 ml/min characterizes normosialia, that of 0.1 ml/min hyposialia.
- the sugar cube test:
This test consists of placing a calibrated sugar cube (No. 4) under the patient’s tongue, and measuring its dissolution time (3 minutes = normosialia). Beyond this, hyposialia is highlighted.
- the gauze absorption test
This involves placing a gauze under the tongue for 5 minutes, then the weight of the gauze is measured. It should normally (for normosialia) absorb 0.1 g of saliva per minute. Below this, it is hyposialia.
- the salivary net test:
The thumb and index finger together are placed in the oral cavity under the tongue, and then spread out of the oral cavity, a 1.5 cm saliva stream should form between the fingers, otherwise, an alteration is objectified.
- the Shirmer test:
A strip of blotting paper is placed in the lacrimal sac, and its impregnation is measured. Less than 10 mm of impregnated paper, there is a dry syndrome.
- saliva pH measurement:
This measurement is done using pH meter paper. Hyposalivation is usually accompanied by its decrease.
other explorations
More in-depth examinations may be requested but must be carefully considered (sialography, scintigraphy, MRI, salivary gland biopsy).
Dry mouth and hyposialia
VIII. Therapeutic strategies:
The management of hyposialia is therefore essential. Unfortunately, there is currently no true curative treatment for hyposialia. The management strategy will be solely palliative and adapted to the intensity of the salivary deficiency.
The following gradient can be proposed:
Mild hyposialia: comfort tips (1)
Moderate hyposialia: (1) + care for dry mouth (2)
severe hyposialia: (1)+(2) + artificial saliva ± hyposialia correctors
Asialie: reservoir prostheses
- The first step is to treat local complications:
- Establish good oral hygiene:
If candidiasis is present: it should be treated in a very traditional way, using fungizone as a mouthwash, or in tablets, if the extent and/or general condition require it.
If a prosthesis is worn, it is advisable to isolate the possibly contaminated intrados from the mucosa. This can be done using gels such as: Fitt de Kerr or Viscogel;
- Treatment of caries;
- Periodontal sanitation;
- Compensation for missing teeth, correction or replacement of inadequate prostheses.
- Comfort tips:
- Hygiene and dietary advice are also very important to pass on:
- The patient must drink plenty of water, and especially regularly, to hydrate the mucous membranes ;
- He should avoid soft and sticky foods, excessive consumption of coffee, tea;
- Smoking and alcoholism should be avoided;
- Chewing hard foods (vegetables and fruits) is recommended;
- The patient should suck on sugar-free sour lozenges to promote salivation;
- In the case of sialoprive medication, contact the treating physician to try to adjust the prescription as far as possible.
- Dry Mouth Care:
- Moisturizing products which include: mild and non-abrasive toothpastes, alcohol-free mouthwashes may be indicated;
- The use of other protective gels may be possible, they can be marketed (Polysilane, Buccagel), or are prepared in a magistral form: 6 sachets of Ulcar (antiulcer Sulphacrate) diluted in 50 ml of sodium bicarbonate, or a mixture of 50% liquid glycerin to 50% lemon water (the glycerin increases the adhesion of the solution to oral surfaces, the lemon stimulates salivation).
- The use of protective sprays may also be indicated (Aequasyal).
- Drug treatments:
These prescriptions are of several types:
- Jaborandi tincture, the effectiveness of which is sometimes disputed;
- Sialogogues: These are tablets prescribed orally, also supposed to stimulate saliva production .
Examples: Salagen 5 mg, 1 tablet 3/day. It is recommended to prescribe this therapeutic dose for 1 month, and to multiply it by 2 for 3 months in case of ineffectiveness.
If the treatment is still ineffective, it is then recommended to suspend it.
- Extreme treatments “reservoir prostheses”:
Artificial saliva systems have also been described. These consist of an extracorporeal reservoir mounted on a pump and connected to the oral cavity by a catheter. The artificial saliva contained in the reservoir is thus mechanically pulsed into the oral cavity at a flow rate that can be adjusted according to the patient’s needs. These systems are very bulky, with an associated risk of infection.
These systems can only be considered in cases of severe Asiania.
Finally, the use of reservoir prostheses may be indicated. The salivary substitute is brought into the reservoir by syringe. The central part of the prosthetic intrados is a removable metal plate (Co/Cr) for easy cleaning. An orifice placed at the extrados of the prosthesis allows the progressive release of the salivary substitute. This system, which is easy to use and maintain, also has the disadvantage of being very cumbersome for the patient.
Dry mouth and hyposialia
Baby teeth need to be taken care of to prevent future problems.
Periodontal disease can cause teeth to loosen.
Removable dentures restore chewing function.
In-office fluoride strengthens tooth enamel.
Yellowed teeth can be treated with professional whitening.
Dental abscesses often require antibiotic treatment.
An electric toothbrush cleans more effectively than a manual toothbrush.