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A Selected Article

 

XEROSTOMIA [Dry Mouth]
and SJOGREN'S SYNDROME

Dr K. David Hay, BDS, FDFRCS, MDSc.
Oral Medicine Specialist, Clinical Co-ordinator
Oral Health Regional Service, Greenlane Hospital
Greenlane, Auckland, N.Z.
October 2002

Every day, over a 24 hour period, the average person produces at least 500ml of saliva.

This material, which is a very complex fluid, is secreted mainly by three paired salivary glands. The largest, the parotid glands, are situated just below the ear and behind the angle of the lower jaw. The sub-mandibular glands are sited just in front of the angle of the lower jaw on its inner surface and the sub-lingual glands which are situated toward the front of the floor of the mouth between the tongue and the inside of the lower jaw.
There are also many minor salivary glands under the mucosal surfaces throughout the oral cavity. Salivary flow rates vary considerably during any one 24 hour period depending on the demand or the current physiological status of the patient, for example:
Unstimulated/resting flow rate - 0.3ml/min [18ml/hour]
Flow rate during sleep - 0.1ml/min [6ml/hour]
Eating/chewing - 4.0-5.0ml/min [240-300ml/hour]
In Sjogren's Syndrome the production of saliva diminishes in proportion to the degree of progressive destruction of the salivary gland tissue. Diagnostic tests for xerostomia [pronounced 'zerro-stow-meeuh'] may include measuring the flow rate of the saliva; scintigraphy [where a dye is absorbed through the duct of the gland and is then measured in the gland substance]; microscopic examination of some of the salivary gland tissue usually removed from either the lower lip or the parotid gland. These special tests, when combined with the patient's history is usually sufficient to confirm the diagnosis. The spectrum of other signs and symptoms associated with the Sjogren's Syndrome may also be present to a variable degree.
 
FUNCTIONS OF SALIVA
 
Saliva is an important component of the environment of the oral cavity for many reasons.
It is a natural cleansing agent of the teeth and gums helping to wash away accumulated food, debris, bacteria and plaque. It lubricates the soft tissues of the mouth including the gums, tongue, palate, floor of the mouth, cheeks and lips and, more importantly, the throat enabling swallowing to easily occur.
 
Saliva contains
  • numerous proteins such as amylase (one of the digestive enzymes which starts the break-down of starch in some foods)
  • immunoglobulins which help to counteract infections and the stickiness of bacteria adhering to the teeth and soft tissue. In xerostomia some proteins may be missing or may be altered in their composition and function.
  • many inorganic elements, such as calcium and phosphate, which help to remineralise the teeth making them less susceptible to dental decay.
  • buffering ['acid soaking up'] systems which neutralise and inhibit the effects of acids produced by the oral bacteria or which are included in the diet.

PROBLEMS

Xerostomia and hyposalivation [less salivary flow than normal] may be a most unpleasant and devastating problem for the patient with Sjogren's Syndrome. Decreases in the quality as well as alterations in the composition of the beneficial constituents of saliva predispose the patient to many problems.
  • The lips may become dry, sore and cracked.
  • A common complaint is a dry and burning tongue.
  • Swollen, tender salivary glands and angular cheilitis [a cracking of the corners of the mouth] can be unpleasant.
  • All the soft tissues of the oral cavity may have a thinner layer of cells than normal and, therefore, may be more susceptible to damage.
  • Taste sensation can be altered because there is inadequate liquid to dissolve tastants in the food so that the taste buds can be activated.
  • Sjogren's patients may be prone to secondary oral infections, principally from the yeast-like organism, Candida albicans, which produces the condition candidosis (thrush_.  Candidosis may present clinically in a variety of forms, the most common being a generalised inflammation of the mucosal (skin) surfaces of the mouth and tongue on which there can be small superficial whitish patches. These may be removed leaving a red area underneath which often bleeds easily. The corners of the mouth may be infected [angular cheilitis] and this is a common problem especially in denture wearers.  Candidosis may be associated with a tender/burning sensation which can be aggravated by hot or spicy foods.
  • Lack of saliva may affect the nutritional status of the individual because eating and swallowing becomes such a time-consuming ordeal, while talking and conversing may become impossible without frequent sips of water or alternative lubricants.
  • Denture wearing may become difficult because dry mouth can significantly add to the problem of retaining and eating with the dentures, which invariably become loose.
  • Of particular importance is the problem of greatly increased dental decay which can occur in patients who have their own natural teeth. In order to understand why the teeth can demineralise or decay so rapidly when there is a dry mouth some understanding of the physiology of the oral cavity is necessary.

 
TOOTH PHYSIOLOGY
 
Tooth structure is rather like reinforced concrete. There is a framework of tough, strong collagen fibres (like the steel framework of a building), around which is deposited the crystalline minerals of the tooth [concrete] that gives the structure its rigidity and toughness. The crystal/mineral part can be dissolved out by acids.
In a patient with normal salivary function there is a balance between the minerals contained in the saliva [which is saturated with calcium salts] and tooth structure. That is, should a small amount of mineral be dissolved out of the tooth, then calcium crystals will tend to be deposited back into the tooth via the saliva. This process is greatly enhanced by the presence of 'fluoride ion' 0which is the reason for the incorporation of fluoride in water and toothpastes) and the re-formation of tooth mineral crystals is rather like the way in which crystals of alum or copper sulphate can be built up in a school chemistry experiment.
 
The structure of the teeth will actually start to dissolve away in solutions where the pH [acidity] is 5.5 or less! The scale which measures degrees of acidity or alkalinity is known as the 'pH' scale, where pH 7 is neutral, pH 14 is highly alkaline and pH 0 i is highly acid.
        pH                            pH                          pH                          pH
         14                            7                            5.5                          0
         |                               |                              |                              |
Highly alkaline               Neutral               Tooth dissolves           Highly acid
 
Thus, normal salivary flows with normal mineral content and normal buffering capacity (normal 'acid soaking up' properties), is a most important physiological mechanism for maintaining the integrity of tooth structure. When saliva is reduced or absent then mineral replacement of tooth structure does not occur, any acid attack on the tooth lasts for longer and, as a consequence, there is a net loss of calcium salts from the tooth structure and dental decay rapidly supervenes.
 
CONDITIONS
 
Under what conditions does the tooth environment become sufficiently acid to cause mineral loss? There are, in fact, two ways in which this can occur.
 
1. Acidic foods and drinks
Food and beverages which are part of the normal diet can vary considerably in acidity or alkalinity. It is important to know that commercially available carbonated fizzy drinks and fruit juices, eg Coke, Fanta, Lemonade, L&P, Fresh Up, Just Juice, McCoy, Twist, Arano etc ( this is not a complete list ), range from pH 3.8-2.4.  Although some fruit juices have a natural acidity all products are adjusted to have pH 3.8 or less in order to prevent bacterial contamination and to prolong shelf life. Lemon and Glycerine Mouth Swabs, designed to 'freshen up the mouth', also have pH 2.4.
 
In other words all these products are capable of dissolving tooth structure and can demineralise the teeth. Such beverages tend to be drunk, sipped frequently or used during the day by people with dry mouth to keep the mouth moist. Usually, in a person with normal salivary flow, not much damage occurs (unless the materials are used habitually or excessively) because the normal compensatory mechanisms described above are active and any adverse effects of food or beverage acids is rapidly eliminated. But tooth mineral loss in a person who has xerostomia can be significant under these conditions because the compensatory mechanisms are absent or reduced. This does not meanthat such drinks should be completely avoided. It does mean that they should not be used continually as mouth moisteners or oral lubricants.
 
2. Dental Decay
 
In the mouth there are some 27 species of micro-organisms (bacteria) to be found. These are considered to be normal inhabitants of the oral cavity in the same way that all parts of the body have a normal resident microflora. In the mouth these micro-organisms grow rapidly over the tooth surfaces forming 'dental plaque'. Plaque is usually partially removed by regular oral hygiene methods such as tooth brushing and flossing but it is impossible to remove every vestige of plaque from all the nooks and crannies of the teeth and gums and after tooth cleansing plaque builds up again quite rapidly by bacterial cell division and multiplication.
 
Some species (families) of plaque micro-organisms use sugars in the diet for their own energy and metabolic requirements. Their waste products are strong organic acids which are excreted into the plaque thus creating an environment around the teeth which is acidic enough to dissolve the minerals out of the tooth. In fact, the acidity of the plaque may fall as low as pH 2.5!
 
In a patient with normal salivary flow the effects of this acid production are, again, quite quickly neutralised by the diluting and buffering action of saliva. When there is reduced or absent saliva the acids remain undiluted, the buffering systems do not work and the tooth structure is exposed to the effects of acid for much longer which, in turn, leads to greatly increased tooth decay. Careful attention to oral and tooth hygiene is important in all patients but is mandatory in those who have xerostomia where plaque control is of vital significance in the prevention of dental decay. Plaque control may be enhanced by the regular use of antiseptic mouth rinses {eg chlorhexidine gluconate 0.2% (products: Savacol by Colgate or Chlorhexidine Mouthwash by Delta West)}. The use of a fluoride containing toothpaste is also recommended.
 
Hence, the action of the oral bacteria on the sugar sweeteners in foods and drinks to produce acidic plaque together with the acidity of the drinks themselves can cause an additive effect and the end result can be an increase in dental decay and tooth demineralisation.
 
MANAGEMENT
 
Xerostomia and its sequelae are managed according to severity.
 
Fluid replacement and Mouth Moistening
The most pressing need so far as the patient is concerned is the need for some sort of fluid replacement in the mouth to diminish oral discomfort and aid speech and swallowing and for the patient to maintain good hydration at all times.
 
1. If there is some secretory glandular tissue working, it can be stimulated by chewing gums for example. This may be sufficient to maintain adequate lubrication in the mouth between meals for talking and normal activities. However, it is vital that if you have your own natural teeth, such gums or sweets are sugar free - otherwise dental decay via conversion of sugar to acids by the microflora in the mouth will occur.
 
2. Glandular massage
When salivary flow rates are diminished, the secretions may frequently become viscous and can be retained within the ductal system. This may cause glandular swelling and tenderness which, of course, needs to be distinguished from infection. There are two pairs of large saliva glands which pour most of the saliva into the mouth. The parotid glands are below the ears and just behind the lower jaw. The submandibular glands are tucked under the lower jaw towards the back.
 
The parotid gland may be ‘milked’ by placing the tips of the fingers on the cheeks just in front of the ear, then pressing firmly whilst dragging the fingers forward over the cheek skin. This has the effect of emptying the parotid duct as it lies just beneath the skin in this region. The manoeuvre can be repeated several times with the fingers being positioned more ‘down and back’ with each stroke, in order to compress and progressively empty the parotid gland. This often clears the gland enabling saliva to flow from the ductal system more freely and can be repeated as often as required.
 
The submandibular gland is more difficult to clear in this fashion. To empty, for instance, the right submandibular gland, the left index finger is placed as far back as possible along the floor of the mouth under the tongue, whilst the index and third fingers of the right hand compress the body of the gland by pressing on the skin under the lower jaw just in front of the angle. The left index finger is then drawn along the floor of the mouth towards the midline, compressing the duct as it lies in this position, expressing secretions from the duct orifice just behind the lower front teeth. Again, this may repeated several times and the positioning reversed for the other submandibular gland.
 
3. Saliva substitutes
These are used when there is insufficient or no functioning glandular tissue or when the previous methods are still inadequate.
 
a) Water
It is highly acceptable at the present time to carry, and sip frequently from, a plastic bottle containing liquid. In patients with xerostomia, water sipped frequently, still remains a very effective, innocuous mouth moistener and doing so in public does not attract attention. Water, however, is a poor lubricant.
 
b) Other oral lubricants/saliva substitutes
A number of preparations have been designed to both moisten and coat the oral tissues in an attempt to mimic saliva but these are surprisingly unsuccessful with respect to consumer compliance. Part of the problem is that of product cost [for commercial products], part because the covering agent in many products is carboxymethylcellulose or related materials which have a ‘greasy’ texture in the mouth that is unacceptable to many patients.
 
c) Recent Anticariogenic materials.
A new non-toxic product based on milk casein designed for use as a mouth moistener, Dentacal Mouth Moistener has very recently become available. This material contains calcium and phosphate and has been shown to be equivalent to a standard fluoride mouth rinse in its ability to reduce dental decay.
 
d) Pilocarpine
The drug Pilocarpine appears to be a useful sialogogue (salivary stimulant) but, as with all drugs, there are side effects and the patient needs to be carefully screened for heart disease, diabetes and other medications first. Although this drug may increase salivary flow, patients can find the side effects unacceptable.
 
DENTAL DECAY
 
1. It can be seen that in order to prevent, as much as possible, the problem of extensive and rapid dental decay and to ensure that dentures are maintained, regular dental examinations are a priority. In the case of those who have their natural dentition a dentist should be able to advise in appropriate oral hygiene techniques eg brushing flossing, antiseptics, fluoride applications/rinses. Use F' toothpastes.
Example products: Savacol [chlorhexidine gluconate 0.2%] Chlorhexidine Mouthwash
Fluoride containing toothpastes
Biotène Antibacterial Dry Mouth Toothpaste (designed to help tooth remineralisation and to replace salivary antibacterial activity by including several ingredients present in normal saliva).
Oralbalance (designed to use with Biotène; contains similar ingredients and enzyme).
 
2. Avoid acid juices and avoid acid oral swabs. Many people resort to using fruit juices/carbonated fizzy drinks to make the mouth feel nice and to keep it damp. Unfortunately, if used habitually, all of these drinks will demineralise the teeth.
 
3. Oral hygiene  In patients with their own teeth, immaculate dental hygiene is mandatory in order to minimise tooth destruction.
    Plaque control:
Brushing (conventional/mechanical)
Flossing
Antiseptic rinses (chlorhexidine, cetylpyridinium chloride)
Fluoride applications/rinses
Fluoride containing tooth pastes
Bicarbonate containing toothpastes
The Biotène‚ (Laclede Inc., USA) product range - antibacterial toothpaste, moisturising gel (Oralbalance), mouthwash and denture adhesive (Denture Grip) are advertised specifically for use in xerostomia
    VERY regular dental recall
Necessary to maintain plaque control
Dental prophylaxis and oral hygiene review
Periodontal care
Dental restorative work as required
Patients may need to be reviewed as frequently as every 4 months. Calculus accumulation
is seldom a problem in xerostomia because of the reduction in calcium salts being
secreted into the mouth.
 
DENTURES
 
In patients with dry mouth, denture wearing can be a major trial because retention of dentures relies considerably on the good fit of the prosthesis but also on the surface tension effect of the viscous saliva under the denture. The saliva 'seals' the edges of the denture preventing air from getting under the appliance which would allow it to drop. In xerostomia this component of denture retention can be largely absent. There are some aids for retaining the dentures which rely on the application of a thick sticky material which causes a semi-adhesion of the denture to the underlying tissues. 
Example products:   Polygrip
                                Fixodent
                                Denture Grip (Biotene)
 
DIETARY ADVICE
 
Attention must be given to diet which should be palatable, edible and nutritious.
Xerostomia can lead to patients becoming socially compromised because of their inability to eat certain foods - those often nominated as the worst are bread and chicken. Many people will not go out to eat because they feel that they may offend their host if they are unable to eat the prepared food or because it takes so long to consume the meal. This can be acutely embarrassing.
 
A dietician may be part of the management team and can offer individual advice concerning suitable food preparation/food types. It must also be noted that many people with xerostomia are unwell and the diet must be practical and within their abilities to prepare. In-between-meals snacks for dentate patients should be minimised as these often tend to be carbohydrate in nature and contain sugars which encourages dental plaque, acid production and demineralisation.
 
BOOKLET   A patient information booklet, ‘Cooking Solutions: For people with dry mouths,’ has recently been compiled which describes the role of saliva, causes and problems of xerostomia and offers hints about diet and food preparation. This is available on application to: Dr David Hay, Oral Health Regional Service, Green Lane Hospital, Green Lane, Auckland ($10.00 per copy).
 
THANKS
We are indebted to Dr. David Hay, the Oral Health Specialist at Green Lane Hospital in Auckland, N.Z. who has very kindly written this comprehensive, up-to-the-minute article about the dry mouths which affect people with Sjogrens. Perhaps many people have more trouble with their mouths than any other Sjogren’s Syndrome symptom.
Felicity, Convenor of Sjogrens Syndrome New Zealand, included this article with her Sjogrens Newsletter No. 27, October 2002 and I am sure everyone will be delighted to understand so much about dry mouths.
We thank both Felicity and Dr. Hay sincerely for being able to bring this article to people's attention.