Xerostomia

Definition
Xerostomia is a complaint form of the dry taste in
the mouth cavity as a result of a decrease in saliva
production (Hyposalivation) or changes in the
composition of saliva. In the event of abnormalities
in the major and minor salivary glands can cause
xerostomia disease. Saliva is often called saliva
came from the salivary glands located in the oral
cavity.Salivary gland consists of the major salivary
glands and the minor salivary glands. Major salivary
gland consists of three pairs of salivary glands, namely the parotid,
submandibular and sublingual located around the neck area. While the minor
salivary glands scattered throughout the oral mucosa. (Lewis 1998)
Etiology
Many people complain of dry mouth even if their salivary glands to function
normally. True Xerostomia can be caused by salivary gland diseases primary or
secondary manifestation of a systemic disorders or drug therapy. (Lewis 1998)
Xerostomia occurs when the amount of saliva that bathes the mucous
membranes of the mouth is reduced. Output is estimated that one liter of saliva
per day. Shortage of saliva or oral dryness can be accelerated by the oral
mucosa dehydration that occurs when output by the major salivary gland, minor
salivary glands and saliva covering layers of the oral mucosa is
reduced. (Guggenheimer 2003)
Xerostomia is also common due to the decrease in volume or change in the
composition of saliva (become concentrated, pH decline and loss of organicinorganic components). There are several causes such as breathing through the
mouth xerostomia (dry mouth False), dehydration, oral candidiasis, febrile,
infiltration of salivary glands, hypercalcemia, head and neck radiotherapy. Other
causes: such as depression (False dry mouth), diabetes mellitus, diabetes
insipidus, hypothyroidism. (Indriyani 2010)
The most common causes of xerostomia is medication. More than 400 drugs are
generally used can cause xerostomia. Types of drugs that can cause xerostomia
among others such as antihypertensives, antihistamines, antidepressants,
anticholinergics, anorexiants, antipsychotics, anti-Parkinson agents, diuretics and
tranquilizers. Patients who complain of xerostomia should be interviewed and the
drugs that they use should be reviewed as by changing medications or doses to
provide increased salivary flow. (University of Montana, 2010)
Pathogenesis
Saliva is produced leh parotid, submandibular, sublingual, and hundreds of minor
salivary glands are distributed throughout the oral cavity. Every day the salivary
glands is estimated menghasilan 1 liter / day, flow rate can fluctuate up to 50%
according diurnal rhythm (Guggenheimer, 2003).
The sympathetic and parasympathetic nervous system innervate the salivary
glands. Innervating parasympathetic more on the "watery secretion" and the
more sympathetic nerves innervate "viscous saliva". Dry mouth sensations

similar to those felt during acute stress caused by the change in the composition
of saliva at the moment sympathetic nerve stimulation more dominant during
this period. In addition to the symptoms of dry mouth is also caused by
dehydration of the oral mucosa in which salivary gland output decreased as well
as minor and major salivary melapisis layer oral mucosa is reduced
(Guggenheimer, 2003).

pancreas (Vernillo, 2003; Pedersen, 2004; Greenberg, 2003). b The mechanism of

pathogenesis between DM and change the function of the salivary glands until
now unclear. Dehydration as a result of hyperglycemia long as a consequence of
polyuria is a major cause xerostomia and salivary gland hypofunction in patients
with DM. Dehydration alone can not lead to changes in salivary gland
function.Lymphocytic infiltrates seen in labial salivary gland tissue indicates that
the salivary gland tissue is the target of an autoimmune process that is similar to
the cell-

Ongoing degeneration in the salivary gland tissue will cause a 10-25% the
composition of salivary hypofunction and disorder. DM type I and II can cause
asymptomatic bilateral enlargement of the parotid gland and submandibular
gland sometimes commonly called sialosis diabeti (Pedersen, 2004).

There are two things that are often a degenerative complications of diabetes,
namely autonomic neuropathy and microangiopathy that cause structural
disturbance in salivary gland tissue and then going to the hypofunction of this
gland and influenced the autonomic innervation and microcirculation in glandular
tissue. Patients with diabetic neuropathy reported an increase and a decrease in
salivary flow. There is no consensus on the relationship between DM and salivary
gland dysfunction. Xerostomia and salivary gland hypofunction is often reported
to be associated DM disease where there is poor metabolic control (Pedersen,
2004).

Clinical manifestation
Decrease in saliva will lead to complaints of dry mouth, burning or pain and the
loss of the sense of taste sensation. Other manifestations possibility is an
increase in the desire to drink water when swallowing. Difficulty swallowing
increases when used for dry food mekan. At the beginning of the clinical
condition xerostomia preceded clinically significant changes in the oral mucosa
or decreased salivary gland function. During the process of xerostomia, the
examination of the oral cavity can terluhat also erythematous pebbled,
cobblestoned or fissured tongue and atrophy of filiform papillae. The oral tissues
redness, burning will cause the finger's adhering.
External palpation of the parotid and submandibular glands by placing a dry
cotton swab will appear duct opening nuisance and do not look any salivary flow
from the duct. In the teeth appear to increase the tendency of caries and
discomfort and loss of use of denture retention. This condition can also increase
the likelihood of infection in the oral cavity and oropharynx as well as candidiasis

and cheilitis. (Guggenheimer, 2003). Hyposalivation and salivary composition

changes associated with an increased incidence of oral infections, impaired
wound healing and increased dental caries (Perseden, 2004), cracking atrophic
mucosa, mucositis, ulceration, diskwamasi and inflammation (Vernillo, 2003).

DIAGNOSIS
Diagnosis to determine the occurrence of xerostomia consists of several stages:
1. The main complaint of patients and disease history.
Most patients who present with dry mouth, but for patients with xerostomia
asymptomatic certain questions may aid in diagnosis, for example:
a. Does saliva in your mouth feels very little, too much or you do not notice?
b. Do you have difficulty swallowing?
c. Is your mouth dry tersa when eating food?
d. Do you need to suck water if it would swallow dry food?
Answer "yes" to "a" in the answer to "too little" indicates a decrease in
unstimulated saliva. Answer "yes" to the following 3 points indicates a decrease
in stimulated saliva.
For symptomatic patients a dentist can use methods of the Visual Analogue Scale
(VAS) that can describe the severity of a patient when it comes and to evaluate
the response of patients after therapy. This method is often used by clinicians for
inspection pain in patients but can also be used for examination of saliva
(Navazesh, 2003).

2. Health history
Although the patient's medical history has been recorded in the medical record
but the evaluation of salivary gland function is rarely done unless the patient
complains adanyanya certain symptoms. Salivary secretion is affected by the
condition, severity, number and duration variations medical disorders and
treatment (Navazesh, 2003).
In patients with DM, of course, require blood glucose tests to diagnose this
disorder. DM diagnosis should be based on blood glucose tests andnot quite
simply on the basis of glucosuria only. DM diagnostic tests performed on
individuals who show symptoms / signs DM (Alim, C, 2007).
Clinical symptoms of diabetes are: polyuria, polidipsi and weight loss is unclear
why (triad) (Hernawan, I, 2006) and when blood sugar levels greater than 200
mg / dL is sufficient diagnosis of DM. At least the necessary checks blood sugar
levels twice as abnormal at different times or two abnormal results at the same
time. When the results of blood glucose levels during doubted it for confirmation
of diagnosis of DM is necessary to Oral Glucose Tolerance Test (Alim, C, 2007).

Overnight fasting blood glucose levels (greater than 10 hours), where the levels
of normal levels 70/80 - 100/120 mg / dL. Fasting blood glucose levels are high
indicates that the production of insulin is not enough though only complains for
basal needs. Fasting blood glucose levels in people with diabetes mellitus above
120-130 mg / dL (Alim, C, 2007). Blood glucose levels post-prandial (PP), namely
blood glucose levels after eating or glucose administration in a certain amount
(such as OGTT) is called blood glucose levels post-prandial. The basis of this
examination is a normal person after eating or drinking the glucose solution in a
certain amount, glkosa blood levels will rise and reach its peak after
approximately one hour PP, then down to the levels at two hours PP approaching
fasting blood glucose levels. In patients with diabetes glucose levels rise and
slow settling once or difficult to return to normal. Oral Glucose Tolerance Test
(OGTT) by means of oral and intravenous (Alim, C, 2007).

3. Clinical examination
Includes examining patients yitu thorough examination of salivary glands, soft
tissues and hard tissues of the oral cavity. Salivary gland examination includes
everything found example enlargement, tenderness, decreased saliva, saliva
contamination (pus or blood) palpation. Examination of soft tissue covering "dry
conditions", state that dries, atrophy, fissures, and discoloration lobulated
mucosa. Dentists can use a tongue blade to see the dryness of mucous, if the
appliance is attached to the mucosa mean decrease salivary secretion. Hard
tissue examination includes examining teeth caries, severity and recurrence
(Guggenheimer, 2003).

4. Follow-up
As a follow-up examination can be by examination alone or in combination to get
a final diagnosis. Examination includes sialometri, serology, microbial, histology
and imaging.
a. Pemeriksaam sialometri
The collection of "whole saliva" is easier to do, can be done at rest (unstimulated
/ resting), and when patients do mastication / activity (stimulated).Unstimulated
normal saliva is 0.1-0.2 ml / minute (g / min) and stimulated saliva is 0.7 ml /
minute (g / min).
Unstimulated saliva was conducted in patients who had been resting the mouth
cavity at least 90 minutes, sitting upright with his head slightly tilted forward, the
situation is quiet, eyes open, then the motion of mastication beginning, saliva
collected every 5 minutes through a funnel into a glass measuring.
Stimulated saliva was conducted in patients who first chewing gum for 45
minutes, then the patient's saliva accommodate every minute for 5 minutes
(Navazesh, 2003).

b. Minor salivary gland biopsy

Histopathological changes in the major and minor salivary glands describe the
influence of local or systemic condition that affects the secretion of salivary
glands. The most frequent biopsy is on the lower lip. This examination is common
to see clusters of lymphocytes (>> 50 lymphocytes in 4 4 mm) were
diagnosed as Sjgren syndrome, so it can be differentiated to diagnose
xerostomia due to other causes (Navazesh, 2003).

THERAPY
The general approach Hyposalivation and xerostomia patient therapy is palliative
therapy that serves to relieve symptoms and prevent complications of oral
(Guggenheimer, 2003). Rehydration therapy, especially for patients with
diabetes mellitus, the stimulation of the salivary glands (masticatory, gustatory,
pharmacotherapeutic), artificial saliva, antimicrobial and fluoride therapy is a
therapy that can be recommended (Navazesh, 2003)
Some of the products can be used in patients with xerostomia eg artificial saliva,
some formulations such as mouthwash, aerosol, chewing gum and dentifrices
which can also trigger the secretion of saliva. Cholinergic agent that stimulates
acetylcholine receptors major salivary glands, namely drugs
parasympathomimetic example pilocarpin hidrochloride although patients
complain less comfortable with the drug usage ini.Jika medical treatment has not
also give a good response it is worth advised memnggunakan alternative
therapies such as acupuncture (Guggenheimer 2003 ).
Patients with systemic symptoms should be given appropriate treatment of
acquired problems. A patient with diabetes (type 1 and 2) should get treatment
of diabetes so well that it becomes a better metabolic control, which is expected
to improve the condition of xerostomia is going through.
Insulin therapy is the mainstay of therapy for patients with diabetes mellitus type
1. There are many metodem pemggunaan insulin therapy that is tailored to the
needs of patients in general tatapi a subcutaneous injection (Kinambi, 2008),
giving Mixture commercial amylin (pramlintide) and Oral Hypoglicemic Agent
(OHA) is The first line of therapy is used for patients with type 2 diabetes, and
serves to increase pancreatic insulin secretion and insulin action (insulin action)
(Kinambi, 2008)