Xerostomia / Hyposalivation

XEROSTOMIA / HYPOSALIVATION

Xerostomia or “dry mouth” as it is commonly known, is a symptom that has affected most people at some point in life. Xerostomia can result from decreased saliva production (hyposalivation), changes in saliva composition, or other unknown factors. Episodes of xerostomia are usually isolated and quickly resolve on their own but some patients suffer from this condition chronically and are subject to serious complications and often marginally effective treatments. Because xerostomia is associated with a widespread number of conditions and medical treatments, this symptom often goes ignored or marginally treated by health care professionals.

Typically, patients suffering from chronic or persistent xerostomia suffer from some form of associated chronic disease or are undergoing treatment for a disease.

ASSOCIATED CONDITIONS

The causes of xerostomia are many and widespread and can include the following:

Medical Conditions

  • Autoimmune Disease
    • Sjögren’s
  • Diabetes Mellitus
  • Sarcoidosis
  • HIV/AIDS
  • Tuberculosis
  • Amyloidosis
  • Depression
  • Allergies
  • Anxiety

Medication/Pharmaceutical Agents

  • Head and Neck Cancer Treatment
    • Radiation therapy
    • Chemotherapy
  • Antidepressants
  • Antihistamines
  • Diuretics
  • Some over the counter drugs
  • Recreational Drugs
    • Marijuana
    • Methamphetamine
    • Tobacco

CONDITION SPOTLIGHT

Cancer

  • Head and neck cancer patients commonly experience xerostomia as a result of radiation treatment. The glands responsible for production of saliva are typically in close proximity to head and neck cancers and are subject to the damaging effects of ionizing radiation treatments. Salivary gland cells are increasingly susceptible to radiation induced DNA damage. Depending on the dosage of radiation and length of exposure, gland dysfunction or total loss of function could result. Treatments for these patients have historically focused on replacement of saliva with oral lubricants and synthetic saliva. Recent medical advances in stem cell technology have led to new treatment options for these patients.

  • Chemotherapy treatment for cancer can affect the production of saliva as well. These patients typically have greatly reduced or completely absent salivary gland function at the completion of their treatment. Treatment options for these patients also traditionally consisted of saliva replacement therapies with varying levels of success. Stem cell therapy may now provide new hope for these patients.

Autoimmune Disease – Sjogren’s Syndrome

  • Sjogren’s syndrome is an autoimmune condition that is characterized by progressive exocrine gland destruction. Sjogren’s is a complex disease process that can vary greatly in severity among patients and involve multiple organ systems.

Patients suffering from autoimmune disease such as Sjogren’s disease commonly have salivary gland involvement with coinciding severe dry mouth (xerostomia) and dry eye (xerophthalmia). The immune system of these patients has selectively targeted certain glandular tissues of the body including the salivary glands. Chronic illness in these patients can result in pronounced gland dysfunction, coinciding xerostomia, and significant impact to quality of life.

HIV/AIDS

  • HIV patients must deal with a multitude of immune system regulation issues and complex medication requirements. Immune system dysregulation and medication side effects in this patient population have been associated with severe xerostomia and parotitis.

Patients with xerostomia complaints oftentimes have a varied and complex medical history. As such, many healthcare providers marginally address or altogether ignore treatment of xerostomia. Quality of life for patients undergoing treatment or recovering from these conditions is a serious concern because untreated xerostomia can lead to a variety of complications and increases in morbidity. Advances in medical technology such as stem cell therapies have increased the options available to patients with chronic xerostomia.

SYMPTOMS OF XEROSTOMIA

  • Dry oral cavity
  • Dental cavities
  • Difficulty swallowing/speaking
  • Oral Candidiasis
  • Infections of the salivary glands (Sialadenitis)
  • Bad Breath (Halitosis)
  • Altered taste sensation
  • Soreness of the gums, tongue, or soft palate

EVALUATION OF XEROSTOMIA

As previously discussed, xerostomia can be associated with a variety of complex and very different medical conditions or pharmaceutical therapies. It is recommended that cases of recurrent or chronic xerostomia be evaluated and treated by a salivary gland specialist. These physicians are experts at recognizing and treating xerostomia/hyposalivation in patients with diverse medical histories. The specialized and focused training obtained by these physicians, allows them to manage even the most complex cases of salivary gland disease or dysfunction.

Patient History

Preliminary evaluation involves extensive review of the patient’s medical background and associated symptoms. Systemic illnesses and medical therapies for seemingly unrelated conditions can frequently result in symptoms of dry mouth. An in-depth history is important in establishing the timeline of symptom onset, frequency, intensity, aggravating/ameliorating factors, and associated activities. Seemingly unrelated symptoms and events can in fact be associated with the underlying cause of xerostomia. This crucial first step in the evaluation assists in developing a list of possible explanations for the patient’s symptoms.

Focused Physical Exam

A focused physical examination is crucial in further pinpointing the cause of a patient’s symptoms. As mentioned before, dry mouth can be due to a variety of diverse medical conditions.

During physical examination the physician can evaluate the integrity and function of the salivary gland system. Saliva flow rates can be objectively measured (sialometry) and analyzed (sialochemistry) to determine if the gland is producing sufficient saliva or if the composition of the saliva is outside normal parameters. The gland itself can be examined manually by gentle palpation to further verify the consistency of the underlying tissue and any notable growths.

Imaging

Imaging (i.e. MRI, CT, Ultrasound) is frequently requested in order to further investigate the integrity of the salivary gland system and if to assist in determining the presence of other disease processes.

Examples

  • Gland tissue is frequently destroyed in some infiltrative diseases.
  • Radiation therapy commonly results in the partial or complete destruction of sensitive glandular tissues.
  • Infiltrative cancers can compromise glandular function and ductal architecture that can result in xerostomia or hyposalivation. Imaging is helpful in determining the presence and extent of these masses.
  • Stones (sialolithiasis) can form within the ducts of the salivary glands. These stones can cause obstruction of salivary flow and lead to infections and swelling of the glands.

Imaging is an important component of the evaluation process and can help to pinpoint the patient’s specific issue.

Diagnostic Procedures

Sialendoscopy

  • Ductal evaluation via sialendoscopy is a cutting edge minimally invasive diagnostic procedure helpful in the evaluation of salivary gland dysfunction, including obstructive disease. Xerostomia can be a symptom of an obstruction within the duct network of the salivary gland. Mineral accumulation within the ducts can lead to formation of an obstructing stone. Alternatively, invasive cancer or other benign growths can also obstruct or compress the ductal system.

Salivary Gland Biopsy

During biopsy, small glandular tissue samples are obtained and undergo microscopic evaluation to determine the cellular integrity of the salivary glands. This information can provide a definitive diagnosis or rule out suspicion of other conditions.

TREATMENT

Saliva Promoting Agents (Sialagogues)

These agents work by promoting increased salivary flow but depend on the integrity of the salivary gland network for correct function. Sialagogues have historically been used with varying levels of success for the treatment of xerostomia.

Artificial Saliva

This class of treatment is intended to lubricate the oral cavity. Since these agents do not promote saliva production, they require frequent reapplication.

Stem Cell Therapy

Stem cell therapy is a revolutionary concept at the forefront of medical research. Recent advances in medical technology and stem cell processing have allowed for investigation into new therapeutic applications, including salivary gland treatment.

Stem cells posses the ability to differentiate into different types of cells. These cells are thought to possess the capacity to promote growth of new tissue. Researchers have shown that stem cells can provide therapeutic effects to damaged salivary gland tissue, ultimately leading to increases in salivary flow rates.

The process of undergoing stem cell therapy is relatively simple. Therapy involves the collection and isolation of stem cells from the patient’s own body. Stem cells are processed and then reintroduced into the patient’s body at the treatment site. This infusion of new cells is believed to promote various aspects of the tissue repair process. Additional benefits of stem cell therapy include reduced likelihood of immune reaction or rejection of treatment by the patient’s immune system.

Stem cell therapy can be of potential benefit to the following groups:

  • Patients that have found conventional therapies to be ineffective or unsatisfactory
  • Patients that have undergone radiation therapy for head and neck cancer

Patients with autoimmune destruction of the salivary glands (i.e. Sjögren’s)

EVALUATION AND TREATMENT CHECKLIST

A comprehensive evaluation of xerostomia should include the traditional components of a comprehensive medical exam but should include consideration of the following critical components:

  • Salivary gland specific history
  • Measurement of saliva flow rate (sialometry) and analysis of saliva composition (sialochemistry)
  • Ductal system evaluation
  • Salivary gland biopsy
  • Medication side effect analysis
  • Analysis of lifestyle and dietary choices
  • Customized treatment trial
  • Presentation of stem cell treatment options

TEAM APPROACH

The Osborne Head and Neck Institute is an internationally renowned center for the evaluation and treatment of salivary gland disorders. The physicians of OHNI have pioneered the use of cutting edge and minimally invasive techniques for the treatment of salivary gland disorders. They have also developed evaluation and treatment protocols centered on increasing quality of life while promoting optimal outcomes.

XEROSTOMIA – AT A GLANCE

Xerostomia or “dry mouth” is a condition that is very common and is associated with a widespread number of medical conditions as well as pharmaceutical agents. 

Causes:

Xerostomia can be caused be any condition or drug that leads to decreases in saliva production or changes in saliva composition. In addition, xerostomia can, at times, have no readily identifiable cause.

Associated Conditions:

Xerostomia is seen in various medical conditions such as autoimmune disorders (i.e. Sjögren’s), diabetes, sarcoidosis, HIV/AIDS, tuberculosis, amyloidosis, depression, allergies, and anxiety disorders.

Xerostomia can also be a side effect of various medical therapies such as radiation therapy, chemotherapy, antidepressants, antihistamines, diuretics, over the counter drugs, tobacco, and various illicit drugs (i.e. marijuana and methamphetamine).

Evaluation

A salivary gland specialist is the medical professional that is most qualified to evaluate and treat xerostomia. A comprehensive evaluation protocol is crucial for timely and accurate assessment of xerostomia.

A comprehensive evaluation will usually include the following components:

  • Salivary gland specific history
  • Measurement of saliva flow rate and analysis of saliva composition
  • Ductal system evaluation
  • Salivary gland biopsy
  • Medication side effect analysis
  • Analysis of lifestyle and dietary choices
  • Customized treatment trial
  • Presentation of stem cell treatment options

Treatments

Treatment for xerostomia includes the following options:

  • Saliva Promoting Agents (Sialagogues) – These agents work by promoting increased salivary flow but depend on the integrity of the salivary gland network for correct function.
  • Artificial Saliva – This class of treatment is intended to lubricate the oral cavity. Since these agents do not promote saliva production, they require frequent reapplication.
  • Stem Cell Therapy – Stem cell therapy is a revolutionary concept at the forefront of medical research. Recent advances in medical technology and stem cell processing allow for new applications, including salivary gland treatment.

Symptoms

Symptoms of xerostomia include:

  • Dry oral cavity
  • Dental cavities
  • Difficulty swallowing/speaking
  • Oral Candidiasis
  • Infections of the salivary glands (Sialadenitis)
  • Bad Breath (Halitosis)
  • Altered taste sensation
  • Soreness of the gums, tongue, or soft palate

Physician

It is recommended that cases of recurrent or chronic xerostomia be evaluated and treated by a salivary gland specialist. These physicians are experts at recognizing and treating for xerostomia/hyposalivation in patients with diverse medical histories. The specialized and focused training obtained by these physicians, allows them to manage even the most complex cases of salivary gland disease or dysfunction.

FREQUENTLY ASKED QUESTIONS

What is Xerostomia?

Xerostomia is the medical term for dry mouth.

Who is affected by Xerostomia?

Xerostomia is a condition that affects millions of people of all backgrounds and age groups. Most people have experienced a case of dry mouth at some point in their life. In these patients, symptoms are temporary and typically last only a short while before resolving. In more advanced cases, patients can experience prolonged symptoms that can become chronic and lead to complications associated with oral hygiene deterioration, infections of the oral cavity, swallowing difficulties, and speech issues.

Severe or chronic cases of xerostomia usually coincide with a chronic illness or treatment for a chronic health condition (i.e. radiation treatment or chemotherapy).

What causes Xerostomia?

There are many factors and conditions that can lead to xerostomia or dry mouth. These varied causes typically fall into one of three groups:

  1. Conditions that alter the composition of saliva
  2. Conditions that decrease the flow or production of saliva
  3. Cases with no identifiable cause

What conditions are associated with Xerostomia?

Xerostomia is seen in various medical conditions such as autoimmune disorders (i.e. Sjögren’s), diabetes, sarcoidosis, HIV/AIDS, tuberculosis, amyloidosis, depression, allergies, and anxiety disorders.

Xerostomia can also be a side effect of various medical therapies such as radiation therapy, chemotherapy, antidepressants, antihistamines, diuretics, over the counter drugs, tobacco, and various illicit drugs (i.e. marijuana and methamphetamine).

Who is at risk of experiencing xerostomia?

Anyone can experience xerostomia symptoms. However, the following risk factors increase the risk of experiencing advanced or prolonged xerostomia symptoms and complications:

  • Cancer
  • Increased Age
  • Multiple medications use
  • Dehydration
  • Depression
  • Tobacco or drug use
  • Systemic or chronic illness

How is xerostomia evaluated?

Xerostomia is associated with a wide variety of medical conditions and can even result from various lifestyle choices. As such, evaluation of this condition requires meticulous examination of a patient’s medical history and current health status. Salivary gland specialists understand that xerostomia can be associated with various chronic medical conditions, medications, and therapies. In those with chronic disease or advanced xerostomia, quality of life can be significantly impacted, further highlighting the need for proper evaluation.

Evaluation of xerostomia should be performed by a salivary gland specialist. A comprehensive evaluation will usually include the following components:

  • Salivary gland specific history
  • Measurement of saliva flow rate and analysis of saliva composition
  • Ductal system evaluation
  • Salivary gland biopsy
  • Medication side effect analysis
  • Analysis of lifestyle and dietary choices
  • Customized treatment trial
  • Presentation of stem cell treatment options

How is xerostomia treated?

Treatment for xerostomia includes the following options:

  • Saliva Promoting Agents (Sialagogues) – These agents work by promoting increased salivary flow but depend on the integrity of the salivary gland network for correct function.
  • Artificial Saliva – This class of treatment is intended to lubricate the oral cavity. Since these agents do not promote saliva production, they require frequent reapplication.
  • Stem Cell Therapy – Stem cell therapy is a revolutionary concept at the forefront of medical research. Recent advances in medical technology and stem cell processing allow for new applications, including salivary gland treatment.

Who is stem cell therapy right for?

Stem cell therapy involves collection and isolation of stem cells from the patient’s own body. This relatively simple process of using ones own cells reduces the likelihood of immune reaction against the treatment. Because stem cells can differentiate into many types of different cells, medical research has shown that these cells can potentially provide increase salivary flow rates.

Stem cell therapy can be potentially helpful to the following groups:

  • Patients that have found conventional therapies to be ineffective or unsatisfactory
  • Patients that have undergone radiation therapy for head and neck cancer

Patients with autoimmune destruction of the salivary glands (i.e. Sjögren’s)

GLOSSARY

Diabetes Mellitus: Endocrine disease characterized by decreased sensitivity or production of insulin hormone.

Halitosis: The medical term for bad breath.

Oral Candidiasis: A fungal infection of the oral cavity caused by the overgrowth of candida fungal organisms.

Salivary Gland: Glandular structures located within the face that are responsible for the production of saliva. The salivary glands include the parotid, submandibular, and sublingual glands.

Sialendoscopy: A procedure used to diagnose and treat salivary gland disease. Very small instruments and cameras are passed through the natural opening of the salivary gland to evaluate and treat issues related to the salivary gland.

Sialadenitis: Bacterial infection/inflammation of a salivary gland.

Sialochemistry: The chemical analysis of saliva to determine its composition.

Sialometry: The collection and measurement of saliva for objective determination of salivary gland function.

Sjogren’s disease: A syndrome characterized by autoimmune dysfunction and progressive destruction of the body’s exocrine glands (e.g. pancreas, salivary glands, etc.).

Stem Cell: Undifferentiated cells that can give rise to cells of different tissues.

Xerostomia: Medical term for “dry mouth”.

CONTACT OHNI