1. XEROSTOMIA

2. DEFINITION
Refers to a subject sensation of a dry mouth. Frequently associated with salivary gland hypofunction.
A common problem in 25% older adults.

3. CLINICAL FEATURES  in salivary secretion
Residual saliva appear foamy or thick and “ropey”
Examining gloves stick to the oral mucosa
Dorsal tongue often is fissured with atrophy of the filiform papillae
Patient may c/o difficulty in mastication and swallowing and may indicate that food adheres to the oral membranes during eating.
Signs: more prone to dental decay especially at cervical and root caries. Associated more often with radiotherapy aka radiation-induction therapy.

4. CAUSES Salivary gland aplasia Impaired fluid intake Hemorrhage
Aetiology
Developmental origin
Iatrogenic origin
Systemic diseases
Local factors
Water/metabolite loss
Impaired fluid intake
Hemorrhage
Vomiting /diarrhea
Medication
Radiation therapy to head and neck
Chemotherapy
Sjogren syndrome
Diabetes mellitus
Diabetes insipidus
Sarcoidosis
HIV
Hep C infection
Graft-versus-host-disease
Psychogenic disorders
 mastication
Smoking
Mouth breathing

5. MEDICATIONS THAT MAY PRODUCE XEROSTOMIA
Class of drug
Example
Antihistamine agents
Diphenhydramine
Chlorpheniramine
Sedatives and anxiolytic agents
Diazepam
Lorazepam
Alprazolam
Decongestant
Pseudihepdrine
Anticholinergic agents
Atropine
Scopolamine
Antidepressant agents
Amitriptyline
Citalopram
Fluoxetine
Paroxetine
Sertraline
Bupropion
Antihypertensive agents
Resepine
Methyldopa
Chlorothiazide
Furosemide
Metoprolol
Calcium channel blockers
Antipsychotic agents
Phenothiazine derivatives
Haloperidol

6. EVALUATION History of present illness
acuity of onset, temporal patterns (eg, constant vs intermittent, presence only on awakening)
provoking factors, including situational or psychogenic factors (eg, whether xerostomia occurs only during periods of psychologic stress or certain activities)
assessment of fluid status (eg, fluid intake habits, recurrent vomiting or diarrhea) sleeping habits
Use of recreational drugs should be specifically elicited.

7. Review of systems
Seek symptoms of causative disorders, including dry eyes, dry skin, rashes, and joint pain (Sjögren's syndrome)
Past medical history
conditions associated with xerostomia, including Sjögren's syndrome
history of radiation treatment, head and neck trauma, and a diagnosis of or risk factors for HIV infection
Drug profiles should be reviewed for potential offending drugs

8. Physical examination
oral cavity,
the condition of the teeth unusual caries site.
specifically any apparent dryness (eg, whether the mucosa is dry, sticky, or moist; whether saliva is foamy, thick, stringy, or normal in appearance)
presence of any lesions caused by Candida albicans
areas of erythema and atrophy
Less common is the better-known white, cheesy curd that bleeds when wiped off.
Tongue depressor
Place on buccal mucosa for 10 sec.
If the tongue blade falls off immediately when released, salivary flow is considered normal
Lipstick Sign
Lipstick adhere to front teeth
Useful indicator
Palpation
 submandibular, sublingual, and parotid glands.
Drying the duct openings with a gauze square before palpation aids observation
Container
Expectorate once to empty mouth. Then expectorate all saliva into container
Normal production is 0.3 to 0.4 mL/min. Significant xerostomia is 0.1 mL/min.

9. Interpretation of findings
Xerostomia is diagnosed by symptoms, appearance, and absence of salivary flow when massaging the salivary glands.
Xerostomia d/t drugs
No further assessment
Xerostomia after H&N radiation
Xerostomia after H&N trauma abrupt onset
May be caused by nerve damage
Concomitant presence of dry eyes,dry skin, rash or joint pain
Suggestive of sjogren syndrome
Severe tooth decay, findings out of proportion
May indicate drug abuse (methamphetamines)
Only during night time or on awakening
Excessive mouth breathing in dry environment

10. Other test Sialometry: salivary flow measurement
Should the presence of xerostomia become unclear:
Sialometry: salivary flow measurement
collection devices are placed over salivary gland orifices
saliva is stimulated with citric acid
Sialogaphy: imaging technique in identifying stones and masses
injection of radio-opaque media into the salivary glands
Salivary scintigraphy
To assess salivary gland function
Biopsy Minor salivary gland
To dx Sjogren Syndrome, HIV-related salivary gl ds, sarcoidosis, amyloidosis and graft-vs- host disease
Biopsy Major salivary gland
Malignancy suspected

11. Management of Xerostomia
Identify the underlying cause
Provide symptomatic treatment where little can be done to alter the underlying cause
It Aims are:
Increase existing saliva flow
Replacing lost secretion
Control dental caries
Control specific measure i.e. infection

12. Treatment
Drug-related xerostomia: cannot changed to another drug. Schedule to optimize drug effect during the day
Custom-fitted acrylic night guards carrying fluoride gel.
Drugs in liquid should be considered than sublingual osage.
Lubricate mouth and throat with water before swallowing cap. Tab. Or b4 sublingual nitroglycerin
Avoid decongestant and antihistamine

13. Symptomatic treatment
drugs that  saliva production:
Cevimeline (30 mg po tid)
An cholinergic agonists
SE: nausea
Pilocarpine (5 mg po tid)
SE: sweating, flushing, polyuria
Other ways to increase saliva secretion
Chewing xylitol-containg gum
Sipping sugarless fluid
OTC saliva substitue containing carboxymethylcellulose, hydroxycellulose or glycerin
Petroleum jelly apply to lips and under denture
Cold-air humidifier my aid mouth breathers

14. Symptomatic treatment
Control caries
Brush and floss regularly; fluoride rinses or gels daily
Use newer toothpaste with added ca and phosphorus may px rampant caries
Individual fitted carriers containing 1.1% Na fluoride or 0.4% SnF
Apply 5% Na fluoride varnish 2-4x/year

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