Nutritional Advice for Patients with Xerostomia

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This entry is adapted from the peer-reviewed paper 10.3390/jcm12144592

Xerostomia and hyposalivation are highly prevalent conditions in old age, particularly among multimorbid elders, and are often attributed to the use of multiple medications. These conditions negatively affect oral functions, such as chewing, swallowing, speech, and taste. Additionally, the lack of lubrication of the oral mucosa frequently leads to super-infections with candida.

nutrition nutritional counselling food choice xerostomia hyposalivation elders geriatric gerodontology

1. Definitions

Xerostomia refers to the subjective sensation of having a dry mouth, which can occur with or without an actual decrease in salivary flow. On the other hand, hyposalivation refers to an objectively reduced salivary flow. A resting saliva flow rate (RSFR) below 0.1 mL/min or a stimulated saliva flow rate (SSFR) lower than 0.7 mL is commonly regarded as pathological. Monitoring the salivary flow during routine dental check-up visits can be beneficial as a reference to assess impairment ^[1].

2. Clinical Symptoms

The clinical manifestations of hyposalivation comprise dry mucous membranes that may stick to the mirror during a dental examination. The mucosal membranes appear pale, thin, and lack lustre. The tongue often exhibits deep grooves, while the lips feel dry and sticky during speech, a phenomenon often accompanied by an inflammation of the corners of the mouth known as cheilitis angularis. Hyposalivation patients are more prone to candidiasis ^[2]. If natural teeth are present, they may exhibit a dull surface and fine hairline cracks on the enamel, resembling the appearance of an antique porcelain vase. Erosion, abrasion, and caries are common, with root caries being a particular concern in patients with receding gums, especially when combined with a diet rich in sugar and carbohydrates ^[3]. The saliva itself appears viscous and is difficult to extract by massaging the parotid gland. Clinically, one may observe whitish, sticky saliva with small bubbles at the corner of the mouth. Difficulties chewing and swallowing specific foods are also common signs of hyposalivation ^[4].

3. Dry Mouth and Nutrition

Reduced salivary flow and the subjective perception of a dry mouth can impair eating and swallowing and lead to oral discomfort, as shown by Dormenval and co-workers in 82 hospitalised geriatric patients ^[5]. Saliva deficiency can also significantly impact taste perception. The taste buds on the tongue detect taste stimuli and transmit signals to the central nervous system through the chorda tympani, a branch of the seventh facial nerve. When saliva is lacking, the transmission of taste signals may be compromised. Matsuo and co-workers conducted an animal experiment in which the salivary glands were surgically removed from some rats ^[6]. All four stimuli, salty, sour, bitter, and sweet, that were presented to the experimental animals showed lower activity potentials in the chorda tympani when the salivary glands had been removed.

Measuring the impact of xerostomia and hyposalivation on food choice in a medical setting requires one of the above-mentioned methods to quantify salivary flow. Other approaches comprise the use of questionnaires or monitoring the patient’s nutritional intake over a given period of time. In most cases, no baseline information would be available as a reference; hence, a before-and-after questionnaire may be necessary, despite the shortcomings of retrospective reporting. In addition, psychological instruments and PROMs might evince the impact of the altered diet on the patient’s well-being and quality of life.

Several studies relying on food questionnaires suggest that xerostomia affects the quantity and quality of food intake and ultimately the quality of life ^[7]^[8]^[9]. For instance, in 1405 adults living in Lithuania, xerostomia was associated with lower intakes of carbohydrates and proteins ^[8]. People aged > 65 years with xerostomia have reduced intakes of omega-3 fatty acids, micronutrients (vitamin E, folate, fluoride), and water ^[10]. Older studies reported that people with xerostomia tended to avoid crunchy, dry, and sticky foods ^[9] and had lower intakes of fibre, potassium, vitamin B6, iron, calcium, and zinc ^[7]. These changes in nutritional intake place people with xerostomia at risk of malnutrition. The European Society of Clinical Nutrition and Metabolism (ESPEN) guideline in geriatrics acknowledges this risk ^[11]^[12]. In cases of malnutrition or risk of malnutrition, this guideline provides guidance for nutritional support and recommends strategies such as reducing or replacing medications that contribute to xerostomia. Furthermore, it recognises xerostomia as a risk factor for dehydration. Dehydration can be treated by oral fluid intake in asymptomatic patients with a serum measured plasma osmolality > 300 mOsm/kg but may require subcutaneous or intravenous hydration in cases of more severe dehydration or failure of sufficient oral fluid intakes.

4. Nutritional Advise for Relief of Symptoms

While scientific evidence for nutritional recommendations specifically tailored to xerostomia may be limited, there are some general guidelines that can help alleviate symptoms and support overall oral health. In addition to ensuring adequate calorie, protein, and fluid intake, nutritional advice should aim to relieve symptoms. To date, these mostly rely on anecdotal evidence and testimonies of patients on the internet or recommendations on websites of learned societies, associations, or dental practices specialised in hyposalivation treatment, cancer associations, or simply derived from common sense. Hence, the derived recommendations listed in Table 1 and Table 2 are non-exhaustive and not based on scientific evidence (Table 1 and Table 2). Of note, smoking should be discouraged as it worsens xerostomia.

Table 1. Drinks and foods having an impact on xerostomia symptoms.

Drinks That May Alleviate Symptoms
Adequate hydration (sips of water, fruit juice or green tea during and outside of meals) Cold fluids
Foods That May Alleviate Symptoms
Soft, moist foods, cool or at room temperature High fat liquids (e.g., gravies, cream, milk, sauces, salad dressings) Soups Ice cream, yoghurt, nutritional supplements Frozen pineapple lozenges, frozen grapes Fruits with high water content (e.g., watermelon) Baby food
Drinks That May Worsen Symptoms
Caffeine containing drinks (e.g., sodas, black tea and coffee) Alcohol (including alcohol-containing mouthwashes), as they increase the risk of dehydration Acidic beverages, as they may be painful for the mucosal membranes
Foods That May Worsen Symptoms
Dry foods (e.g., bread, biscuits, toasts, cake, crackers) Hot, spicy and salty foods Acidic foods (e.g., fresh fruits), as they may be painful for the mucosal membranes Mechanically irritating foods Mushy and sticky foods (e.g., banana, dried fruits, chocolate, honey, jams)

Table 2. Foods having stimulating saliva secretion.

Foods/Chewing Devices That May Foster Salivary Flow

Sugar-free herbal lozenges or liquorice
Moderately acidic and preferably sugar-free candies, beverages and sherbets
Non-acidic chewing-active visco-elastic foods (chewing gum or Chewy Tubes^®)

Liquid intake is particularly important for dry mouth patients. Meals should be well-seasoned, although hot and spicy condiments that irritate the mucous membrane should be avoided. As a general rule, meals should be served with lots of gravy. Dry foods, such as biscuits, can be better enjoyed with fruit or green tea. Black tea and coffee, as well as alcohol, on the other hand, increase dehydration and should not be excessively consumed. Thick foods such as yoghurt or ice cream relieve dry mouth symptoms. Sucking lozenges should not be too acidic or contain sugar, as the latter increases the risk of caries and tooth loss. Although acidic fruits may be painful for inflamed mucous membranes, they can still be enjoyed when steamed or baked. High-water-content fruits like watermelon are also recommended. If the mucous membrane is already painfully inflamed, ice cream, an ice cube, or even lozenges from frozen pineapple can cool and soothe. For severe cases, like oncology patients, a viable option is baby food in jars, as it is easy to eat and provides essential nutrients.

Patients need to be advised that mushy and sticky foods should be avoided as they stick to the mucous membranes and the formation of a cohesive bolus may be difficult. When not cleared by the tongue and cheeks, the remaining food can also lead to tooth decay and inflammation of the periodontal tissues, especially if oral hygiene is not performed thoroughly because of the sensitivity and painfulness of the mucous membranes. It should also be avoided to treat the mucous membranes with petroleum-based ointments, such as Vaseline. These dry out the oral mucosa even further and prevent the natural washing away of pathogenic germs ^[13]. It is important to know that the combination of xerostomia and poor oral hygiene can lead to rapidly progressing root caries and tooth loss within a very short time. Patients with dry mouth should therefore always receive dental care and nutritional advice ^[14].

The last and probably least satisfactory relief for dry mouth is moistening the oral cavity with small sips or spray shots from a vaporizer of water. Tea, gels, or mouthwashes during the day may provide immediate, but not long-lasting, relief. Ultimately, replacement with artificial saliva is recommended. It is important to consult with a healthcare professional, such as a dentist or doctor, to determine the most suitable artificial saliva product and usage instructions based on individual needs and preferences. They can provide guidance on the appropriate application and frequency of artificial saliva use for optimal relief.

5. Nutritional Advise for Stimulating Saliva

Amidst all nutritional guidance, as aforementioned, the utmost important advice is to ensure an adequate intake of fluids, with small “reminders” encouraging the patient to drink a sufficient quantity throughout the day.

Furthermore, some other nutrients may help stimulate salivary flow, such as visco-elastic foods that increase salivation by stimulating the periodontal receptors via occlusal load during chewing (Table 2). Salivation can also be stimulated by unilateral chewing of sugar-free gum ^[15]. The salivation effect of chewing gum was mentioned already, but regrettably, the act of chewing gum is not particularly favoured by the elderly population. At the age of 85, 6 out of 10 Swiss people wear removable dentures ^[16]. In this regard, it is unfortunate that all chewing gums presently accessible on the market adhere to denture acrylic, thus rendering the act of chewing exceptionally arduous. This problem may be overcome by recommending silicone tubes of different hardness and surface textures with a large handle to hold. These tubes were conceived to train the chewing muscles during facial growth in children with Duchenne syndrome. However, they may also be used to stimulate salivary flow by unilateral mastication. In this regard, geriatric patients with poor chewing efficiency should not be promptly prescribed a mixed diet, as the benefits of chewing solid food are evident. Before doing so, a dental examination should verify if the patient’s capacity to eat a normal diet can be regained by restorative means.

Salivation can also be stimulated by sucking on sweets, although sour drops may cause dental erosion and are therefore less suitable than aromatic lozenges or liquorice. Care should also be taken to ensure that they contain no sugar to prevent the development of tooth decay.

Recent trends in geriatric medicine confirm a strategy to prioritize medications to reduce the total number of prescribed drugs ^[17].

References

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Update Date: 27 Jul 2023

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