magazine(oral hygiene)

Zeroing in on Xerostomiapage 1

March 2013

Perio Reports Vol. 25 No. 3page 2

MARCH 2013 » hygienetown.com1

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7 Profile in Oral Health: Substances for Targeting Xerostomia

Zeroing in onXerostomiaby Trisha E. O’Hehir, RDH, MSHygienetown Editorial Director

Three years ago Linda Douglas submitted a PowerPointCE course on xerostomia to be part of Dentaltown.com’s CEofferings. It’s an in-depth look at xerostomia and currenttherapies. Her interest in this area began when she noticedmore and more patients with xerostomia. Patients who hadbeen stable for years were suddenly experiencing root caries orcaries in odd places like incisal edges of anterior teeth or cuspsof canines. Douglas’ strong desire to support these patientsand prevent further destruction launched her journey intothe world of saliva.

She read the literature, took courses and asked many ques-tions of those working in the area of saliva and xerostomia.After learning so much, she wanted to share these insights inan engaging way with her colleagues who found this topicrather “dry” (pun intended). To do this, Douglas created aone-hour, engaging CE course that has been viewed by manyTownies and spurred many message board discussions on thetopic. She has become known as “that hygienist who has a‘thing’ about saliva.” Other Townies come to her for answersand send links to new xerostomia literature. To Douglas, thestudy of xerostomia is a constant work in progress.

The online CE course was just the beginning. Thismonth we have a follow-up article on the ingredients inprescription and over-the-counter products for xerostomia.In April, Douglas will be speaking at the 2013 TownieMeeting in Las Vegas. She joined Toastmasters to gain theskills and confidence to present to her colleagues in April.When asked if she would recommend other Towniesdevelop a CE course, she said, “Yes indeed! I would highlyrecommend it. Pick a topic that interests you, and thataddresses the needs of your patients and your practice.Then search the literature and ask fellow Townies for input.Townies are each other’s greatest resources!” �

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The importance of saliva to oral and overall health isoften overlooked by those outside the dental profession.Saliva is important for protection of hard and soft tissues,enamel mineralization and remineralization and digestion.Xerostomia is the subjective feeling of dry mouth andhyposalivation is the objective measure of salivary flow.Aging is not responsible for reduced salivary flow, but themedications taken by the elderly do cause xerostomia.

The following four steps help clinicians detect early signsof salivary gland hypofunction. First, ask questions aboutdry mouth with a visual analog scale for scoring: Do youhave too much or too little saliva in your mouth? Do youhave difficulty swallowing? Does your mouth feel dry whileeating? Do you sip liquids to help swallow dry foods?

Second, review medical history and body systems. Sjogren’ssyndrome, rheumatoid arthritis, scleroderma, hypothyroidism,depression and eating disorders all impact salivary flow.Tobacco, alcohol and drug use will all affect salivary flow.

Third, complete a thorough clinical evaluation. Howdoes the patient appear to you? Examine and palpate thesalivary ducts. Are they enlarged or tender? Can you elicitsaliva with palpation? Does the saliva pool? Visually checkoral tissues for dryness. Use a tongue blade against the buc-cal mucosa to test for dryness. Check hard tissues for caries.Look at the lips for signs of dry, chapped or fissured appear-ance. Is the tongue dry, erythematous, lobulated or fissured?

Fourth, based on findings of the first three steps, furtherdiagnostic tests may be needed. These tests range from

measuring salivary flow to surgical biopsyof a salivary gland.

Clinical Implications: Several clinicalsteps provide valuable information indetecting salivary gland hypofunction. �

Navazesh, M.: How Can Oral Health Care Providers Determine if Patients

Have Dry Mouth? JADA 134: 613-620. 2003.

Measuring Saliva in Clinical Practice

Biomarkers in saliva provide diagnostic information onoral, ovarian and breast cancer; HIV infection; Sjogren’sSyndrome; and dental caries and periodontal disease. Salivais also used to measure alcohol and illegal drug use and nico-tine and cotinine levels associated with tobacco use.Physiologic changes associated with pregnancy and depres-sion can also be detected in saliva.

Saliva collection can be from one or a mixture of glandsand stimulated or unstimulated. Major salivary glands provide90 percent of saliva, with minor glands providing the remain-ing 10 percent. Whole saliva is contaminated with food,micro-organisms and gingival crevicular fluid and consists of99 percent water and one percent proteins and salts. Totaldaily output is between 0.5 liters and 1.5 liters. Minor salivaryglands provide lubrication and protection for mucosal tissues.

Unstimulated saliva is primarily from the submandibularglands and is both serous and mucous in nature. Stimulatedsaliva is from the parotid gland primarily and is completelyserous in nature. The sublingual gland contribution to eitherstimulated or unstimulated saliva is minimal.

Reduced salivary flow negatively impacts the quality oflife by causing difficulty with speaking, eating, swallowingand tasting. Objective measures are needed to accuratelydetermine xerostomia. Salivary flow is simulated with gumbase, paraffin wax, rubber bands and citric acid, and is col-lected by the patient spitting all saliva into a collectioncup. Unstimulated salivary flow is collected from the mouthby having the patient tip his or her head forward and with anopen mouth, allowing all salvia to run out of the mouth andinto the collection container.

Clinical Implications: Dental practices have a variety of clinical means to measure salivary flow. �

Navazesh, M., Kumar, S.: Measuring Salivary Flow: Challenges and Opportunities. JADA 139; (suppl 2): 35S-40S, 2008.

Perio Reports Vol. 25, No. 3Perio Reports provides easy-to-read research summaries on topics of specificinterest to clinicians. Perio Reports research summaries will be included in eachissue to keep you on the cutting edge of dental hygiene science.

Four Steps to Identify Early Salivary Gland Hypofunction

www.hygienetown.com �

continued on page 3



Salivary Flow Rates in the Elderly

Dry mouth is reported by elderly patients, but isnot necessarily related to hyposalivation. Subjectivefeelings of dryness are reported in some who havenormal salivary flow rates.

Researchers at the University of Helsinki inHelsinki, Finland, evaluated a group of 368 elderlypeople. This was a subgroup of a larger medical studyof the elderly. Both stimulated and unstimulated sali-vary samples were collected from the group, however,some of the subjects showed signsof motor and cognitive impair-ment so samples were collectedfrom 60 subjects for each of thesaliva tests. They were also inter-viewed and asked 14 questionsabout oral dryness and dryness ofthe throat, eyes, nose and skin.

Of this group, 46 percentcomplained of some oral dryness.Continuous dry mouth wasreported by 12 percent of thegroup. Others reported dry mouth in the morning(36 percent), during the day (19 percent) and in theevening (16 percent). Common complaints weredryness while speaking, taste impairment, difficultyswallowing dry foods and dry lips. Extra-oral dry-ness was reported for dry eyes and dry skin. Morewomen than men reported dry mouth symptoms.

Waking up at night to drink was reported by 34percent. It was not just water that they drank, but alsojuice, soft drinks, milk and beer. This may be a signif-icant factor in caries risk among the elderly. Thosetaking medications also reported more oral dryness.Mouth breathing causes evaporation of saliva, leadingto dry mouth and increasing risk of caries.

Clinical Implications: Look for dry mouth morefrequently in women, those who mouth breatheand those who take medications. �

Narhi, T.: Prevalence of Subjective Feelings of Dry Mouth in the Elderly. J Dent Res 73(1):

20-25, 1994.

Clinical Signs that Predict Low Salivary Flow Rates

Salivary gland hypofunction leads to several problemsincluding caries, periodontitis, mucositis, angular cheilitisand altered taste. “Dry mouth” was first described in the lit-erature in 1868 and xerostomia in 1889. It wasn’t until 1967

that standardized methods for measuringsalivary flow rates were introduced in a studyof 50 patients with xerostomia. In 1987 itwas reported that questions about drymouth helped identify those who neededfurther salivary tests.

Researchers at the University ofPennsylvania School of Dental Medicinedesigned a study to compare subjects withand without normal salivary flow. The groupconsisted of 23 men and 48 women rangingin age from 19 to 82 years, the average being

52 years. Subjects underwent the tests three times at differ-ent times during the day, to take into account the influenceof circadian rhythm. A total of 64 measures were taken oneach patient, each time. Measurements were taken for lipdryness, buccal mucosa dryness, salivary pooling, salivarygland palpitation, tongue, periodontal tissues and totalDMFT. Salvia collection included stimulated and unstimu-lated whole saliva. Additionally, saliva samples were collectedfrom right and left parotid glands.

A diagnosis of salivary gland hypofunction relies on sali-vary flow rate measures. This study demonstrated that othermeasures could reliably predict those who will have salivaryhypofunction, but not the cause of the hypofunction.Together lip dryness, buccal mucosa dryness, salivary glandpalpation for flow and DMFT scores successfully identifiedthose with low salivary flow test scores.

Clinical Implications: Together, checking dryness of thelips and buccal mucosa, total DMFT and absence ofsaliva with gland palpitation are accurate signs of sali-vary gland dysfunction. �

Navazesh, M, Christensen, C., Brightman, V.: Clinical Criteria for the Diagnosis of Salivary Gland

Hypofunction. J Dent Res 71 (7): 1363-1369, 1992.

continued on page 5

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Salivary clearance of sugar from the mouth isimportant for reducing risk of dental caries. Previousresearchers studied the changes in the total volume

of saliva secreted in responseto 2mL of acid held in the mouth for one minute.What they were unable todetermine was if the salivaryflow rate changed duringthe exposure to the acid.

Researchers at theUniversity of Manitoba inWinnipeg, Canada deviseda method to measure flowrate changes in saliva when

the subject was exposed to sugar, sodium chloride orcitric acid. Twelve young adults, six men and sixwomen participated in this study. Saliva flowed fromthe subject’s mouth into a funnel beaker that sat on

a balance that measured each 0.01mL increase in thesalivary flow rate.

The three test tastes were introduced in a fluidstate and removed immediately over an exposuretime of three minutes, followed by a washout periodusing only water until salivary flow rate stabilized. Arest period of five minutes was allowed betweentests. A high and a low concentration were tested foreach taste, providing six tests per subject.

The delay between the taste stimulation andmaximum salivary flow rate was 9.4 seconds. Fromthis point, the flow rate half-life was determined tobe 11 seconds even though the taste stimulationcontinued for three minutes. There were no statisti-cally significant differences in salivary flow ratesbetween the three tastes tested. Regarding sugar,taste adaptation reduces salivary flow rates, thusslowing clearance of the sugar.

Salivary Clearance of Sugar from the Mouth

The Importance of Saliva in Preventing Caries

Enamel will demineralize at a pH of 5.5, dentin at a pHof six. Plaque pH drops below 5.5 within three minutes ofexposure to sucrose, flour or other fermentable carbohy-drates. Saliva is responsible for returning the plaque pH to alevel that does not lead to enamel demineralization. Reducedsalivary flow results in a great drop in plaque pH and a longerrecovery time. Besides neutralizing the acids produced inplaque biofilm, saliva has the ability to remineralize enamelor dentin that has been demineralized. In 1966 Dr. BackerDirks reported on 70 seven-year-old children with a total of72 white spots lesions that were monitored over eight years.Of these lesions, nine progressed to cavitation, 26 werearrested and unchanged and 37, more than half, were rem-ineralized and no longer detectable clinically.

The increased prominence of sugar- and flour-containingfoods is a risk for dental caries, but food alone is not respon-sible. Stimulated saliva is instrumental in elevating the pH of

plaque. Saliva contains bicarbonate and the concentrationincreases with prolonged stimulation of salivary flow, favor-ing elevation of the pH and remineralization of enamelrather than demineralization.

Several studies demonstrate the value of chewing sugar-less gum after meals to stimulate salivary flow and elevateplaque pH. Sorbitol-sweetened chewing gums are not alwaysbetter than no-gum groups but have been reported to reducecaries from zero to 20 percent while xylitol-sweetened gumsreduce caries 43 to 71 percent, depending on dose and dailyfrequency, three versus five exposures each day. Stimulationof salivary flow from gum chewing plus xylitol reduces cariesrates significantly.

Clinical Implications: Stimulating salivary flow after eating can reduce the incidence of dental caries. �

Stookey, G.: The Effect of Saliva on Dental Caries. JADA 139: 11S-17S, 2008.

Clinical Implications: These findings show full sali-vary clearance of sugar takes 25 to 45 minutes. �

Dawes, C., Wantanabe, S.: The Effect of Taste Adaptation on Salivary Flow Rate and

Salivary Sugar Clearance. J Dent Res 66(3): 740-744, 1987.



hygienetownprofile in oral health

by Linda Douglas, RDH

Nowadays, clinicians encounter increasing numbers of indi-viduals with xerostomia-related problems. According to a recentHygienetown poll, 73 percent of participants are seeing morepatients with xerostomia compared to one year ago.

Salivary lubrication, repair, lavage, antimicrobial and buffer-ing properties contribute significantly to the maintenance of theintegrity of the hard and soft oral tissue.1 Saliva also moistensand lubricates the food bolus, and the esophagus. A dry mouthcan lead to multiple complications,2 for example: cracked lips,angular cheilitis, fissured tongue, dental hypersensitivity, andcaries on roots and cusp tips; plus opportunistic infections suchas candidiasis. It can also impair speech, taste, mastication andswallowing. Impaired swallowing (dysphagia) could causeoesophageal damage, and compromise nutritional status; dys-phagia might also lead to choking, resulting in pulmonary aspiration of food and pneumonia. These problems require amultifaceted approach to management.

To achieve this, management of salivary gland hypofunc-tion (SGH) and xerostomia can be based on seven main goals:

1. Hydration (adequate water intake is crucial)2. Stimulation of salivary flow3. Saliva substitution 4. Reduce the loss of functional salivary gland tissue5. Prevent caries, and promote remineralization 6. Prevent soft tissue injury and infections7. Improve comfort

There are a variety of xerostomia relief preparations availablethat help to achieve these goals; this article discusses the con-stituents of dry mouth relief preparations, and the rationales fortheir use.

Stimulation of Salivary Flow

According to the Commission on Oral Health, Research andEpidemiology, stimulation of secretion has a great advantage ofproviding the benefits of natural saliva.3 Salivary glands arehighly responsive to stimulation of taste, masticatory muscles,and sensory nerves of the oral mucosa and periodontal ligament.Stimulation of salivary flow is valuable for responders, whoretain some salivary gland activity; most salivary gland hypo-function cases are responders.

Masticatory stimulation is achieved by chewing sugar-free gum, preferably with xylitol. A regular chewing gumhabit also causes a prolonged increase in unstimulated sali-vary flow rate.4

Gustatory stimulation5 is achieved by using flavorings, sugarsubstitutes and buffered fruit acids.

Systemic Sialagogues6 might be prescribed, if not contra-indicated.

Drug-free options for stimulation of salivary flow includeacupuncture,7 electronic stimulation8 and hypnosis.9

Increased salivary secretion aids gastric digestion, as whenswallowed, saliva stimulates gastric secretions.

1. Mandel ID.The role of saliva in maintaining oral homeostasis. J Am Dent Assoc.1989;119:298-304

2. Dawes C. Physiologic factors affecting salivary flow rate, oral sugar clearance, and the sensation of dry

mouth in man. J Dent Res. 1987;66(special issue):648-653

3. Saliva: its role in health and disease. Working Group 10 of the Commission on Oral Health, Research and

Epidemiology (C.O.R.E.) Int Dent J. 1992;42(4 Suppl 2):291-394.

4. Laurence J. Walsh, Clinical Aspects of salivary biology for the dental clinician:Minim Interv Dent 2008; 1: 7-24

5. Porter SR, Scully C, Hegarty AM. An update of the etiology and management of xerostomia. Oral Surg

Oral Med Oral Pathol Oral Radiol Endod. 2004;97:28-46

6. Fox PC. Salivary enhancement therapies. Caries Res. 2004;38:241-246.

7. Johnstone PA, Niemtzow RC, Riffenburgh, RH. Acupuncture for xerostomia: clinical update. Cancer.

2002;94:1151-1156

8. Efficacy and Safety of an Intraoral Electrostimulation Device for Xerostomia Relief: A Multicenter,

Randomized Trial; Frank P. Strietzel, Wolff A, et al. J Rheum, Vol. 63, No. 1, January 2011, pp 180–190

DOI 10.1002/art.27766

9. J Pain Symptom Manage.2009 Jun;37(6):1086-1092.e1. Epub 2009 Jan 31.Hypnosis for postradia-

tion xerostomia in head and neck cancer patients: a pilot study.Schiff E Mogilner JG Sella E Doweck

I Hershko O Ben-Arye E Yarom N SourceDepartment of Internal Medicine B, Bnai Zion Medical Center,

P.O. Box 4940, Haifa 31048, Israel. [email protected]

10. Ship, Mc Cutcheon, Spiivakovsky (2007) Safety and effectiveness of topical dry mouth products contain-

ing olive oil, betaine and xylitol in reducing xerostomia for polypharmacy induced dry mouth

11. Jensdottir et al, J Dent Res 85(3): 226-230, 2006

12. Yuan J, Tohara H, Mikushi S, et al. The effect of “Oral Wet” for elderly people with xerostomia—the effect

of oral rinse containing hialuronan. Kokubyo Gakkai Zasshi. 2005 Mar;72(1):106-10.

13. Lee JH, Jung JY, Bang D. The efficacy of topical 0.2% hyaluronic acid gel on recurrent oral ulcers: com-

parison between recurrent aphthous ulcers and the oral ulcers of Behçet’s disease. J Eur Acad Dermatol

Venereol. 2008 May;22(5):590-5.

14. Fox PC, Cummins MJ, Cummins JM. Use of orally administered anhydrous crystalline maltose for relief

of dry mouth. J Altern Complement Med. 2001;7:33-43

15. Linear response of mutans streptococci to increasing frequency of xylitol chewing gum use: a randomized

controlled trial [ISRCTN43479664] Kiet A Ly, Peter Milgrom, Marilyn C Roberts, David K Yamaguchi,

Marilynn Rothen, and Greg Mueller BMC Oral Health. 2006; 6: 6. Published online 2006 March 24.

doi: 10.1186/1472-6831-6-6. PMCID: 1482697

16. Han SJ, Jeong SY, Nam YJ, Yang KH, Lim HS, Chung J. Xylitol inhibits inflammatory cytokine expres-

sion induced by lipopolysaccharide from Porphyromonas gingivalis. Clin Diagn Lab Immunol. 2005

Nov;12(11):1285-91. 11.

17. Dr. Stephen Hsu, Georgia Health Sciences University College of Dental Medicine. New lozenge clinical

trial for dry mouth treatment March 2011



Saliva Substitution

Saliva substitutes are generally formulations that aim toreplicate or approximate the composition and functions ofnatural saliva in order to protect the hard and soft oral tis-sues, improve comfort, and facilitate speech, mastication andswallowing.

Constituents of Dry Mouth Relief Preparations

• Most preparations contain a combination of ingredients,10

which work together to achieve the goals of xerostomiamanagement.

• Water- based products are best, as natural saliva is 99 per-cent water.

• Milk proteins and amino acids such as betaine (trimethyl-glycine) approximate the protein content11 of saliva: theyform a protective coating on the hard and soft oral tissue,which lubricates and retains moisture. Mucin-basedpreparations remain in the mouth for longer than othermuco-protective substances, and therefore need to be usedless frequently.

• Oils, for example evening primrose oil, oxygenated glyc-erol triesters and olive oil also have dry mouth relievingproperties: they coat, lubricate and protect the oralmucosa; olive polyphenols may also have plaque inhibit-ing properties.

• Folic acid aids healing of trauma and apthous ulcers.Hyaluronic acid12 adds moisture, and may also be benefi-cial for apthous ulcers.13 Lanolin, beeswax or plant oilproducts lubricate dry lips.

• Bicarbonate, calcium and phosphate buffer acids.Calcium and phosphate combined, as in Recaldent, workwith fluoride to promote remineralization. Fluoride andRecaldent are also good desensitizing agents, as are potas-sium nitrate, and Pro-Argin (a complex of arginine andcalcium carbonate).

• Sweeteners, such as anhydrous crystalline maltose,14

buffered fruit acids and various flavorings provide gusta-tory stimulation of salivary flow. Xylitol15 is a sweetener,which is a valuable component of any protocol for promo-tion of healthy saliva. It is a non-fermentable crystallinealcohol obtained from birch bark, which, in addition tostimulating salivation, reduces the oral population ofMutans Streptococci. When ingested by Mutans Streptococci,they starve and are rendered unable to replicate. Researchon long-term xylitol supplementation has also found thatxylitol inhibits growth and inflammatory cytokineexpression of porphyromonas gingivalis.16 Xylitol also hasa low glycaemic index (7) and has little effect on bloodsugar levels.

• Chamomile tea stimulates salivation, and improves thecomfort of a dry mouth. Jaborandi leaf17 is from a plantused in South and Central America to promote saliva pro-duction, and green tea polyphenols reportedly reduce freeradical damage to the salivary glands.17

continued on page 9

Fig. 1: Composition of Natural Saliva

Water 99 percent

Saliva is hypotonic to plasma, in order to dilute food to the osmolality

of plasma.

Proteins

Peptides (e.g., histatins, crystatins, cystatins)

Antibodies

Immunoglobulins

Mucins (glycoproteins)

Gustin (carboanhydrase)

Lactoferrin

Growth factors (epidermal, fibroblast and nerve)

Enzymes

Salivary Amylase

Lingual Lipase

Lysosymes

Salivary Peroxidase

Phosphatase

Ribonucleases, Proteases

Minerals

Electrolytes Buffers

Sodium Bicarbonate

Magnesium Calcium

Potassium Phosphate

Also: Zinc, Fluoride* Glucose, Urea, and Ammonia.

*The concentration of fluoride in saliva is related to its consumption.



• Hydrophilic, demulcent substances (often with mucilage)such as aloe vera and carrageenan improve comfort. Theyadd moisture, form a protective coating on the oralmucosa, and have a “slippery” feel, which replicates theviscosity of saliva.

• The enzymes lysozyme, and lactoperoxidase, and an iron-binding protein, lactoferrin, replicate the antimicrobialproperties of natural saliva. Peroxidase enhances produc-tion of hypothiocyanite, an antibacterial ion present innatural saliva.

• Synthetic peptides such as Histatin/P-113 have beentested as an antimicrobial component of oral gels.18

Prescription Preparations

The dental surgeon or MD might prescribe the followingpreparations:

• Systemic sialagogues such as pilocarpine and cevimelinestimulate salivary flow, and slow the loss of functionalsalivary gland tissue. These drugs have limitations, dueto their contraindications, and side effects, whichinclude flushing, sweating, rhinorrhoea and diarrhea;they are contraindicated for individuals with asthma,acute iritis, acute-angle glaucoma, cardiovascular dis-ease, or a history of kidney or bile stones. In addition,pilocarpine cannot be taken by patients with chronic


Amino acids

and oils coat,

lubricate

and protect

Buffer,

remineralize,

desensitize

Fig. 2: Ingredients Used in Dry Mouth Preparations

»

Betaine (trimethylglycine) – an amino acid found in beets, broccoli, and spinach

Castor oil Oxygenated glycerol triesters

Cottonseed oil Milk proteins

Evening primrose oil Mucin

Glycerin Olive oil

Sodium bicarbonate Neutral fluoride

Calcium Potassium nitrate-desensitizes

Phosphate Arginine and

Recaldent calcium carbonate (Pro-Argin)

Xylitol – also reduces cariogenic bacteria Buffered Citric acid

Anhydrous crystalline maltose Sodium citrate

Sorbitol – (also a humectant) Malic acid

Aloe Vera (a succulent plant) Carboxymethylcellulose

Nopal (prickly pear cactus) Hydroxylethylcellulose

Slippery elm

Carrageenan

Linseed

Xanthan gum

Folic acid – for aphthous ulcers

Hyaluronic acid – for aphthous ulcers, and to add moisture

Lanolin, beeswax, coconut oil, almond oil or shea butter – for lips

Lysozyme Essential oils: peppermint,

Lactoperoxidase eucalyptol, thymol and

Lactoferrin wintergreen dissolve

Synthetic peptides (Histatin/P-113) mucopolysaccarides in biofilm

Green tea – an anti-oxidant, which might reduce salivary gland damage

Chamomile, ginger, jaborandi leaf, rhubarb – promote salivation

Sweeteners

and flavorings

for gustatory

stimulation of

salivary flow

Hydrophilic,

demulcent

(often with

mucilage) add

moisture, coat,

and protect

Healing and

protecting

soft tissue

Antibacterial

Other plant

extracts

Fig. 3: Some Products

for Relief of Xerostomia

and Related Conditions

ACT Total Care Dry Mouth

(with fluoride)

Biotène Oral Balance

BioXtra

Epic

CloSYS – Chlorine dioxide to help

prevent candidiasis

Entertainer’s secret spray –

with Carboxymethylcellulose

GC Dry mouth gel

KY jelly

MI Paste with Recaldent

Numoisyn

Oasis

OMNI TheraSpray, TheraMints,

TheraGum

Optimoist

Orex

Oxyfresh

Salese Soft Lozenges with sustained

release technology

Salivasure

Saliva Orthana – with porcine gastric

mucin.

Spry Rain – spray with xylitol

Xero Lube

Xerostom – toothpaste, rinse, spray

and gel with xylitol, fluoride,

olive oil and betaine

18. J Clin Periodontol. 2002 Dec;29(12):1051-8. Safety and clinical effects of topical histatin gels in humans with experimental gingivitis. Paquette DW, Simpson DM, Friden P, Braman V, Williams RC.

obstructive pulmonary disease or those tak-ing beta-blockers.

• Initial research results on cevimeline gargle19

have been inconsistent.• Research is also being conducted on pilocarpine

rinses.20 Pilocarpine HCI has been shown to beeffective when used as a mouthwash for one minute inhealthy individuals. Some clinicians have also prescribed5mg pilocarpine lollipops for 20 to 30 seconds, approxi-mately every two hours.

• Amifostine21 is a chemoprotective and radioprotectivedrug, which is administered intravenously. It acts as a freeradical scavenger in the tissues, to reduce the incidence ofxerostomia and mucositis resulting from chemotherapy orradiation therapy.

• Alcohol-free chlorhexidine rinses reduce the oral popula-tion of pathogens, cariogenic bacteria and opportunisticmicro-organisms.

• Allopurinol rinse is used for chemotherapy-inducedmucositis. It neutralizes uric acid, which is produced as aresult of tumor necrosis syndrome.

• Caphosol is used for for xerostomia and mucositis. It is anelectrolyte solution with calcium and phosphate ion. It isanti-inflammatory, and promotes repair of damagedmucosal surfaces by diffusing into intracellular spaces inthe epithelium and permeating mucosal lesions.

• Sucrose sulfate aluminum complex adheres to ulceratedtissue. It is a buffer and is also cytoprotective.

Chronic Candidiasis

This is a common complication of a dry mouth, which canbe treated with the following:

• Systemic anti-fungals – Fluconazole 200mg for three daysonce per month; this dose reduces the risk of resistance tothis medication. Nystatin does not work as well forchronic candidiasis.

• Oral rinses for burning mouth – Some clinicians prescribedaily prednisone rinses 5mg/5ml for patients with a burn-ing mouth related to chronic candidiasis – this seemscounterintuitive, but it can help to control the rednessand soreness associated with chronic candidiasis.

•• Flucinomide 0.05% (or various strengths)•• Clobetasol 0.05%•• Betamethosone diproprionate 0.05%•• Tacrolimus 0.01-0.1%

• Prednisolone 15mg per 5ml• Dexamethosone (0.5mg/5ml) presents problems with sys-

temic absorptionThe 2011 Cochrane systematic review of topical therapies

for dry-mouth management found that there is no strong evi-dence that any topical therapy is effective for xerostomiarelief. Further research utilizing well-designed, randomizedcontrolled trials are required to provide evidence to guideclinical care. However, integrated mouth care systems, forexample, combining toothpaste, gel and mouthwash, showedpromising results, and chewing gum appears to increase salivaflow in those with residual secretory capacity.22 A multifac-eted approach using combinations of the above strategies andsubstances could be helpful in maintaining oral health andquality of life. There are now many preparations at our dis-posal. The information in this article could help cliniciansand patients to make informed choices. �



19. Y Takagi, Y Kimura, and T Nakamura; Ann Rheum Dis. 2004 June; 63(6): 749. doi: 10.1136/ard.2003.012633. PMCID: 1755032

20. Bernardi R, Perin C, Becker FI, et al. Effect of pilocarpine mouth wash on salivary flow. Braz J Med Biol Res. 2002; 35(1):105-110

21. Kouvaris JR, Kouloulias VE, Vlahos LJ. Amifostine: the first selective-target and broad-spectrum radioprotector. Oncologist. 2007 Jun;12(6): 738-47. Review. PMID: 17602063 [PubMed - indexed for MEDLINE]

22. Cochrane Database Syst Rev.2011 Dec 7;(12):CD008934. doi: 10.1002/14651858.CD008934.pub2. Interventions for the management of dry mouth: topical therapies. Furness S, Worthington HV, Bryan G, Birchenough

S, McMillan R, Source Cochrane Oral Health Group, School of Dentistry, The University of Manchester, Coupland III Building, Oxford Rd, Manchester, UK, M13

Author’s Bio

Linda Douglas is originally from London, England where she studied dental assisting at the Eastman Dental Hospital and graduated from the

Dental Hygiene Program at the Royal Dental Hospital. She has lived and worked in Toronto, Canada for 22 years. Her desire to improve support

for xerostomic patients has instigated an in-depth study of saliva and xerostomia management.

“Integrated mouth care systems, for example,

combining toothpaste, gel and mouthwash,

showed promising results, and chewing gum

appears to increase saliva flow in those

with residual secretory capacity.”

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