1. XEROSTOMIA
Physiology, Etiology, Epidemiology, Pathogenesis, Diagnosis, and Treatment
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2. XEROSTOMIA After viewing this lecture, attendees should be able to:
describe the oral anatomy and physiology related to salivary function as well as the role of saliva in the oral cavity.
discuss the etiology and epidemiology of xerostomia.
relate treatment options for xerostomia.

3. DEFINITION OF XEROSTOMIA
“Xero” = Dry & “Stomia” = Mouth
Xerostomia can be defined as the subjective sensation of oral dryness that may or may not be associated with a reduction in salivary output.1,2 It can have profound negative effects on the quality of life.3
Subjective complaint of patient
Diagnosis based on patient complaint and history
Salivary flow can be measured but no normal limits have been established
Xerostomia: The subjective sensation of oral dryness that may or may not be associated with a reduction in salivary output.
Diagnosis based on patient complaint and history
Salivary flow can be measured, but no normal limits have been established

4. XEROSTOMIA Production of Saliva
Oral Glandular Tissue3 (saliva secreting) Begins development at 6 weeks gestation and is completed by about the 12th week The glandular tissue continues to enlarge until birth
Saliva secreting oral glandular tissue begins development at 6 weeks gestation and is completed by about the 12th week.
The glandular tissue continues to enlarge until birth.

5. NORMAL FUNCTION OF SALIVA3
Hydrating–moisturizing
Cleansing
Lubrication
Digestion
Remineralization of dentition
(pH maintenance, buffering)
Maintenance of mucosal integrity
Immunity mediator
Antimicrobial (antifungal, antibacterial)
Stimulation of minor salivary glands
Cellular maintenance
Enables swallowing
Enables tasting
Enables speech articulation
(Saliva secreting)

6. Cause one of two divisions Sympathetic Parasympathetic
XEROSTOMIA
Mechanisms of Salivary Production3
Salivary glands
Neural innervation
Cause one of two divisions
Sympathetic Parasympathetic
Sympathetic neural innervation causes very dry, thick, ropy saliva.
Parasympathetic neural innervation causes thin, watery, profuse saliva.
The two divisions work in opposition and have the ability to alter the quality as well as the quantity of saliva.
Causes very dry, thick, ropy saliva
Causes thin, watery, profuse salivation
The two divisions work in opposition and have the ability to physiologically alter the quality as well as the quantity of the saliva

7. Salivary Gland Classifications by Secretion3
XEROSTOMIA
Salivary Gland Classifications by Secretion3
Serous: very thin and watery
Mucous: very thick and viscous
Mixed secretions: mixture of the two

8. Salivary Gland Classifications by Secretion3
XEROSTOMIA
Salivary Gland Classifications by Secretion3
Serous: very thin and watery
parotid gland
lingual glands of von Ebner
(serous glands of von Ebner)
Mucous: very thick and viscous
Mixed secretions: mix of the two
Serous secretions are very thin and watery.
Secreted by the parotid gland, the lingual glands of von Ebner
Serous acini

9. Salivary Gland Classifications by Secretion3
XEROSTOMIA
Salivary Gland Classifications by Secretion3
Serous: very thin and watery
Mucous: very thick and viscous
palatine glands
posterior lingual glands
labial buccal glands
Mixed secretions: mix of the two
Mucous secretions are very thick and viscous.
Secreted by the palatine glands, the posterior lingual glands, and the labial buccal glands.
Mucous acini

10. Salivary Gland Classifications by Secretion3
XEROSTOMIA
Salivary Gland Classifications by Secretion3
Serous: very thin and watery
Mucous: very thick and viscous
Mixed secretions: mix of the two
Sublingual glands
Mostly mucous with some serous
Submandibular glands
Mostly serous with some mucous
Anterior lingual glands
Mixed secretion
Mixed secretions are a blend of serous and mucous secretions.
The sublingual glands secrete a mix that is mostly mucous with some serous.
The submandibular glands secrete a mix that is mostly serous with some mucous.
The anterior lingual glands also secrete a mixed product.
Mixed: mostly serous acini (dark), partially mucous acini (light cells)

11. Salivary Gland Classifications by Major or Minor Glands3
XEROSTOMIA
Salivary Gland Classifications by Major or Minor Glands3
Major glands
Secrete saliva intermittently
Minor glands
Secrete saliva continuously
Major glands secrete saliva intermittently.
Minor glands secrete saliva continuously.

12. XEROSTOMIA The Major Glands Parotid gland Parotid gland3,4
Largest of the 3 major glands
Produces 30% of total saliva output
Parotid duct is also known as
Stenson’s duct
Parotid/Stenson’s duct exits opposing
the maxillary second molar
Located anterior but inferior to the external auditory meatus
Innervated by sympathetic and parasympathetic divisions
Secretes serous type saliva
The parotid gland is the largest of the 3 major glands. It produces 30% of total saliva output.
The parotid duct is also known as Stenson’s duct. It exits opposing the maxillary second molar.
The parotid gland is located anterior but inferior to the external auditory meatus. It is Innervated by sympathetic and parasympathetic divisions and secretes serous type saliva.

13. XEROSTOMIA The Major Glands Submandibular gland Submandibular gland3,4
Second largest salivary gland
Produces % of total saliva output
The duct is called Wharton’s duct
Wharton’s duct exits on the floor of the mouth opposing the lingual surface of the tongue
Located in a depression on the lingual side of the mandibular body
Innervated by parasympathetic nerve endings and possesses NO sympathetic receptors
The parasympathetic fibers arrive through the facial and glossopharyngeal nerves
Mixed secretion – mostly serous
The submandibular gland is the second largest salivary gland. It produces % of total saliva output.
The duct is called Wharton’s duct; it exits on the floor of the mouth opposing the lingual surface of the tongue.
The submandibular gland is located in a depression the lingual side of the mandibular body. It is innervated by parasympathetic nerve endings and possesses NO sympathetic receptors. The parasympathetic fibers arrive through the facial and glossopharyngeal nerves.
The submandibular gland produces mixed secretion – mostly serous.
Submandibular gland

14. XEROSTOMIA The Major Glands Sublingual glands3,4
Smallest of the major glands
Produce less than 5% of total saliva output
Saliva delivered via the ducts of Bartholin
The Bartholin ducts exit on the base of the lingual surface of the tongue
Innervated by parasympathetic fibers
Little or no sympathetic influence
Mixed secretion – mostly mucous
The sublingual glands are the smallest of the major glands. They produce less than 5% of total saliva output.
Saliva is delivered via the ducts of Bartholin, which exit on the base of the lingual surface of the tongue.
The sublingual glands are Innervated by parasympathetic fibers and have little or no sympathetic influence.
They secrete a mixed secretion – mostly mucous.
Sublingual gland

15. XEROSTOMIA The Minor Salivary Glands3
Minor salivary glands are found throughout the mouth:
Lips
Buccal mucosa (cheeks)
Alveolar mucosa (palate)
Tongue dorsum and ventrum
Floor of the mouth
Together, they play a large role in salivary production.
Minor salivary glands are found on the lips, buccal mucosa, alveolar mucosa, tongue, and the floor of the mouth.
Together, they play a large role in salivary production.

16. XEROSTOMIA Salivary Flow3
Unstimulated Flow (resting salivary flow―no external stimulus)
Typically 0.2 mL – 0.3 mL per minute
Less than 0.1 mL per minute means the person has hyposalivation
Hyposalivation – not producing enough saliva
Stimulated Flow (response to a stimulus, usually taste, chewing, or medication [eg, at mealtime])
Typically 1.5 mL – 2 mL per minute
Less than 0.7 mL per minute is considered hyposalivation
Unstimulated salivary flow is salivation with no external stimulus. Typically 0.2 mL to 0.3 mL per minute.
Less than 0.1 mL per minute is hyposalivation (not producing enough saliva).
Stimulated salivary flow is salivation in response to a stimulus (usually taste, chewing food). Typically 1.5 mL to 2 mL per minute.
Less than 0.7 mL per minute is hyposalivation.

17. XEROSTOMIA Salivary Flow3
The average person produces approximately 0.5 L – 1.5 L per day
Salivary flow peaks in the afternoon
Salivary flow decreases at night when the parotid gland shuts down
There is a difference in the quality between stimulated and unstimulated saliva
Salivary flow tracks a circadian rhythm and increases in the springtime.
The average person produces approximately 0.5 L – 1.5 L per day.
Salivary flow peaks in the afternoon and decreases at night when the parotid gland shuts down.
There is a difference in the quality between stimulated and unstimulated saliva

18. XEROSTOMIA Salivary Composition1 90% of saliva is water
10% is composed of inorganic and organic ions, and cellular components
sodium, potassium, and calcium are positive ions (cations)
chloride, bicarbonate, and phosphates are negative ions (anions)
The cationic and anionic components play an important role in the function of saliva
Saliva is 90% water, 10% inorganic and organic ions and cellular components.
Sodium, potassium, and calcium are cations (positive charge).
Chloride, bicarbonate, and phosphates are anions (negative charge).

19. XEROSTOMIA Ions and Salivary Flow3
As saliva passes through the salivary ducts, cations (sodium and chloride) are reabsorbed into the adjacent blood vessels.
As saliva passes through the salivary ducts, cations (sodium and chloride) are reabsorbed into the adjacent blood vessels.

20. XEROSTOMIA Ions and Salivary Flow3
In exchange, the body releases bicarbonates and potassium.
As saliva passes through the salivary ducts, cations (sodium and chloride) are reabsorbed into the adjacent blood vessels. In exchange, bicarbonates and potassium are transferred from the blood vessels into the salivary ducts.

21. XEROSTOMIA Ions and Salivary Flow3 Stimulated Salivary Flow
Saliva passes through the salivary duct very rapidly (a negative result of fast flow)
It impedes the exchange of sodium and chloride for potassium and bicarbonate
Unstimulated Salivary Flow
Has a high content of potassium and bicarbonate (a positive result of slow flow)
The quality of unstimulated saliva will change when flow increases because of a stimulus (chewing gum, thinking about lemons, looking at a food you crave)
Stimulated salivary flow causes rapid passage through the salivary duct and thus impedes the exchange of sodium and chloride for potassium and bicarbonate.
Unstimulated salivary flow is slower and thus has a high content of potassium and bicarbonate.
The quality of unstimulated saliva will change when flow increases because of a stimulus (chewing gum, thinking about lemons, looking at a food you crave).

22. XEROSTOMIA Fluoride and Saliva3
Fluoride is also secreted in saliva. Unlike the ions in saliva, the fluoride content (level) is not altered whether the salivary flow is simulated or unstimulated.
Fluoride content is not altered regardless of stimulated or unstimulated salivary flow.

23. Organic Components of Saliva3
XEROSTOMIA
Organic Components of Saliva3
Enzymes:
Amylase – converting starch into glucose and fructose
Lysozymes – prevents bacterial infections in the mouth
Histatins – prevents fungal infections
Secretory IgA – immunity mediator
Lactoperoxidases – stimulation of minor salivary glands
RNase and Dnase – cellular maintenance
Lipase – initiates digestion of fat
Kallikrein – vasoreactive substances
Amylase – converting starch into glucose and fructose
Lysozymes – prevents bacterial infections in the mouth
Histatins – prevents fungal infections
Secretory IgA - immunity mediator
Lactoperoxidases - stimulation of minor salivary glands
RNase and DNase - cellular maintenance
Lipase – initiates digestion of fat
Kallikrein- vasoreactive substances

24. Cellular Composition of Saliva3
XEROSTOMIA
Cellular Composition of Saliva3
The cellular composition consists of:
Epithelial cells
Neutrophils
Lymphocytes
Bacterial flora
Cellular components of saliva include epithelial cells, neutrophils, lymphocytes, bacterial flora.
Neutrophils and lymphocytes are white cells that function in immune response

25. XEROSTOMIA: Epidemiology
Factors that Affect Salivary Flow
Medication
Autoimmune disease (Sjogren’s syndrome, lupus)3
Systemic diseases (diabetes, asthma, kidney, sarcoidosis, HIV)3
Stress/anxiety/depression5
Radiation therapy to the head and neck3
30 Gy = glandular fibrosis (gland can still produce some saliva)
60-70 Gy = glandular destruction (gland can no longer produce saliva)
Gender (70 % female, usually postmenopausal3)
Sympathomimetic medications (stimulate the sympathetic nervous system)6
Parasympatholytic medications (inhibit the parasympathetic nervous system)6
Circadian rhythms (decreases in the fall and increases in the spring)

26. XEROSTOMIA: Epidemiology
Factors that Affect Salivary Flow
Over 400 Medications Can Produce the Side Effect of Xerostomia7
Antacid
Antianxiety
Anticholinergic
Anticonvulsant
Antidepressant
Antiemetic
Antihistamine
Antihypertensive
Antiparkinsonian
Antipsychotic
Bronchodilator
Cholesterol reducing
Decongestant
Diet pills
Diuretic
Hormonal replacement therapy
Muscle relaxant
Narcotic analgesic
Sedative

27. XEROSTOMIA: Epidemiology
Factors that Affect Salivary Flow
Age2,8
Studies show that among non-institutionalized people not taking medication, neither the quantity or quality of saliva change significantly with age
Studies show a positive correlation between the number of drugs taken and the incidence and severity of xerostomia
Studies show that among non-institutionalized people not taking medication, neither the quantity or quality of saliva change significantly with age.
Studies show a positive correlation between the number of drugs taken and the incidence and severity of xerostomia.

28. XEROSTOMIA: Etiology “Dry Mouth”
Xerostomia is the term used for the symptom of oral dryness. While oral dryness is most commonly associated with a reduction in salivary gland output (termed salivary gland hypofunction), the symptom may be reported by patients with apparently normal salivation who have changes in saliva composition.1
While oral dryness is most commonly associated with a reduction in salivary gland output (termed salivary gland hypofunction), the symptom may be reported by patients with apparently normal salivation who have changes in saliva composition.

29. XEROSTOMIA: Etiology Prevalence
Xerostomia affects 25% of the population and is becoming one of the fastest-growing oral health problems in North America3,5
Medications are the cause of more than 90% of xerostomia cases
32 million Americans today take three or more medications daily
Xerostomia was not a great problem in the past because people did not
take as many medications as they do today5
Xerostomia affects 25% of the population and is becoming one of the fastest-growing oral health problems in North America1,9
Medications are the cause of more than 90% of xerostomia cases
32 million Americans today take three or more medications daily
Xerostomia was not a great problem in the past because people did not take as many medications as they do today9

30. XEROSTOMIA: Etiology Global Prevalence
The reported prevalence of dry mouth varies widely due to the methodological and population differences in various studies. Prevalence has been estimated to range from 10% to 38%,9-12 with 20% the most commonly reported figure2,3 Xerostomia is becoming increasingly common in developed countries where adults are living longer and poly-pharmacy is very common.13
The reported prevalence of dry mouth varies widely due to the methodological and population differences in various studies. Prevalence has been estimated to range from 10% to 38%, with 20% the most commonly reported figure.
Xerostomia is becoming increasingly common in developed countries where adults are living longer and poly-pharmacy is very common.

31. XEROSTOMIA: Diagnosis
“The approach to managing the patient has to follow a logical progression. It should be part of a comprehensive evaluation. Symptoms should be noted and signs should be recognized in order to properly diagnose the condition. Treatment should be based on all of that gathered information.”5
– Joseph L. Perno, DDS, FAGD
Special Report – AGD Impact

32. XEROSTOMIA: Diagnosis
Symptoms3,5
Viscous saliva
Sticky saliva
Difficulty speaking
Difficulty swallowing
Halitosis
Altered taste
Complaint of dryness
Complaint of burning mouth, lips, or tongue
Altered sense of smell

33. XEROSTOMIA: Diagnosis
Signs3,5
Increased caries
Food sticking to the oral structures
Frothy saliva
Gingivitis
Absence of saliva
Cracking and fissuring of the tongue
Ulceration of oral mucosa
No pooling of saliva in the floor of the mouth
Recurrent candidal infections
A toothbrush, mouth mirror, or instrument that sticks to the soft tissues
Poorly fitting prostheses

34. XEROSTOMIA: Diagnosis
Two Approaches
Increase Salivary Flow
Using drugs that mimic or stimulate the parasympathetic division of the autonomic nervous system3
These are typically only used for radiation therapy or Sjogrens’ syndrome-induced xerostomia
They have adverse side effects including: sweating, urination, stuffy nose, lacrimation, and abdominal pain.
Using citric acid–containing lozenges and candy that are sugar-free1,5
This approach may decrease the pH into an acidic range. Salivary pH is between 6.0 and 7.0. The critical pH where enamel erosion begins to be seen is reported to be below 5.5
Saliva Substitutes
Over-the-counter products are indicated for medication-induced salivary hypofunction or xerostomia3,5
A. Increase Salivary Flow
1. Parasympathetomimetic drugs mimic or stimulate the parasympathetic division of the autonomic nervous system
1. Pilocarpine
2. Cevimeline
These are typically only used for radiation therapy or Sjogrens’ syndrome-induced xerostomia
Very effective so long as there is salivary gland tissue remaining, but they have adverse side effects including: sweating, urination, stuffy nose, and lacrimation.
2. Using citric acid–containing lozenges and candy that are sugar-free
This approach may decrease the pH into an acidic range. Salivary pH is between 6.0 and The critical pH is reported to be below 5.5 where you begin to see enamel erosion
B. Saliva Substitutes
Over-the-counter products are indicated for medication-induced salivary hypofunction or xerostomia.
May be composed of several ingredients, including carboxymethylcellulose, sorbitol, xylitol, methylparaben, and citric acid.

35. XEROSTOMIA: Diagnosis
Simple Management Strategies for Patients3,14
Perform oral hygiene at least 4 times daily, after each meal and before bedtimes
Use fluoride toothpaste
Rinse with a salt and baking soda solution 4 to 6 times daily
Avoid citrus juices (oranges, grapefruit, tomatoes)
Rinse and wipe oral cavity immediately after meals
Keep water handy to moisten the mouth at all times
Avoid liquids and foods with high sugar content
Avoid rinses containing alcohol and salty foods
Brush and rinse dentures after meals
Apply prescription-strength fluoride get at bedtime as prescribed
Use moisturizers regularly on the lips
Try salivary substitutes or artificial saliva preparations

36. XEROSTOMIA: Management
Treatment Challenges14
Some patients are predisposed to candidiasis because of the lack of salivary histatins
Recommendation:
Antifungal medication can be recommended to control fungal growth
Denture patients also face challenges
Dentures do not adhere to the tissues and are not retained as well
Lack of lubrication increases the frictional forces between the dentures and the oral mucosa, causing sores
Alveolar bone continues to resorb throughout life―dentures no longer fit properly
Denture wearers are prone to inflamed tissues, called denture stomatitis (usually fungal)
Be sure the denture correctly adapts to the denture-bearing tissues
Optimize the patient’s tissue health
Apply oral lubricants or saliva substitutes just before eating
Candidiasis (thrush) is a fungal infection of the oral mucosa. Commonly referred to as a “yeast infection.” Antifungal medication can be recommended for treatment.
Denture challenges include:
Dentures don’t adhere to the tissues and are not retained as well
Lack of lubrication increases the frictional forces between the dentures and the oral mucosa, causing sores
Alveolar bone continues to resorb throughout life―dentures no longer fit properly
Denture wearers are prone to inflamed tissues, called denture stomatitis (usually fungal)
Treatment recommendations include:
Be sure the denture correctly adapts to the denture-bearing tissues
Optimize the patient’s tissue health
Apply oral lubricants or saliva substitutes just before eating

37. XEROSTOMIA: Management
Treatment of Xerostomia-Associated Problems14

38. XEROSTOMIA: Management
Treatment of Xerostomia-Associated Problems14

39. XEROSTOMIA GETTING INVOLVED IN DIAGNOSING XEROSTOMIA
CAN BE A WINDOW TO YOUR PATIENTS’ OVERALL HEALTH
Diagnosing xerostomia is an important diagnostic tool for other systemic diseases. The signs and symptoms of xerostomia are often associated with and/or result from other conditions.
Reformatted

40. XEROSTOMIA: References
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2. Nederfor T. Xerostomia: Prevalence and pharmacotherapy. Wed Dent J Suppl 116: 1-70, 1996
3. Crossley H. Unraveling the mysteries of saliva: its importance in maintaining oral health. Transcript of a lecture presented on August 6 at
the 2006 AGD Annual Meeting & Exposition. Gen Dent. 2007;55)4):
4. Netter FH, Jansen JT. Atlas of Human Anatomy. 3rd ed. Teterboro, NJ: Icon Learning Systems; 2003.
5. Gater L. Understanding xerostomia. AGD Impact. 2008;June(Special Report):26-30.
6. Urquhart D, Fowler CE. Review of the use of polymers in saliva substitutes for symptomatic relief of xerostomia. J Clin Dent. 2006;17(2):29-
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7. Kroll B. Dry mouth. The pharmacist’s role in managing radiation-induced xerostomia. Pharma Pract. 1998;14:72-82.
8. Shirodaria S, Kilbourn T, Richardson M. Subjective assessment of a new moisturizing mouthwash for symptomatic management of dry
mouth. J Clin Dent. 2006;17(2):45-51.
9. O’Grady NP: Incidence of dry mouth complaint in Cork Dental Hospital population. Stoma (Lisb). 1990;2(17): 55-56, 58.
10. Osterberg T, Birkhed D, Johnannson C, Svanborg A. Longintudinal study of stimulated whole saliva in an elderly population. Scand J Dent
Res. 1992;100(6):
11. Thomson WM, Brown RH, Williams SM. Medication and perception of dry mouth in a population of institutionalized elderly people. NZ
Med J 106: , 1993
12. Locker D: Xerostomia in older adults: A longitudinal study. Gerodontology. 12:18-25, 1985.
13. Edgar WM, O’Mullane DM. Saliva and Oral Health. 2nd ed. London: British Dental Journal Brooks; 1996.
14. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2009;138(September–Special
Supplement):15S-20S.

41. XEROSTOMIA
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