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Prevalence of xerostomia and its association with systemic diseases and medications in the elderly: a cross-sectional study

ABSTRACT

BACKGROUND:

Dry mouth syndrome or xerostomia is defined as decreased salivary flow or hypofunction of salivary glands. Its origins are multicausal and might be the result of a change in the salivary glands or a systemic imbalance.

OBJECTIVE:

To ascertain the prevalence of self-reported xerostomia and to identify associated factors.

DESIGN AND SETTING:

Cross-sectional study on the entire population of 293 elderly people over 60 years of age living in a Brazilian municipality.

METHODS:

Data were gathered from a questionnaire that asked about demographic data, chronic diseases and use of continuous medications, and which used the Xerostomia Inventory (XI) to evaluate dry mouth sensation. Our analysis consisted of multivariate regression and estimation of odds ratios (OR) and their respective 95% confidence intervals (CI) in binary logistic regression models.

RESULTS:

The prevalence of self-reported xerostomia was 19.1%. Elderly people with diabetes had higher odds of having self-reported xerostomia (OR: 3.59; 95% CI: 1.48-8.68; P < 0.001) as did those who had chronic diseases and used continuous medication (OR: 2.3; 95% CI: 1.19-4.67; P = 0.009). Elderly people who used continuous medication for the gastrointestinal tract were more likely to have xerostomia (OR: 2.14; 95% CI: 1.03-1.44; P = 0.030).

CONCLUSIONS:

Elderly people with diabetes and chronic diseases who were using continuous medication were more likely to have dry mouth. Use of continuous medications for the gastrointestinal tract led to a greater chance of having self-reported xerostomia.

KEY WORDS (MeSH terms):
Chronic disease; Diabetes mellitus; Drug effects [subheading]; Aged; Xerostomia

AUTHORS’ KEY WORDS:
Elderly; Diabetes; Effect of drugs; Hyposalivation; Dry mouth

INTRODUCTION

Saliva plays an important role in oral health. Besides being involved in protection against bacteria and fungi, it transports nutrients and digestive enzymes, lubricates the mucosa, facilitates mastication, swallowing and speech, and acts in the process of tooth remineralization.11. Pedersen AM, Bardow A, Jensen SB, Nauntofte B. Saliva and gastrointestinal functions of taste, mastication, swallowing and digestion. Oral Dis. 2002;8(3):117-29. PMID: 12108756; https://doi.org/10.1034/j.1601-0825.2002.02851.x.
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,22. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138 Suppl:15S-20S. PMID: 17761841; https://doi.org/10.14219/jada.archive.2007.0358. Erratum in: J Am Dent Assoc. 2008;139(3):252-3. Saliva is produced by salivary glands, which are exocrine, such as the parotid, submandibular and sublingual glands. These are the most important pairs of glands and are responsible for 95% of saliva production.33. Caneschi WF, Paiva CCAN, Frade RL, Motta AR. Use of elastic bandage associated with speech therapy in the control of sialorrhea (hypersalivation). Rev CEFAC. 2014;16(5):1558-66. http://dx.doi.org/10.1590/1982-021620149813.
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In addition, there are other smaller-sized glands throughout the oral cavity, lips and tongue, which help in the process of salivation. These structures produce saliva at certain moments and respond to a series of sensory, taste and olfactory stimuli.

The volume of saliva production may vary according to stimulation. The salivary flow is greater after meals and lower during sleep. In healthy individuals, there is, on average, 1000 ml to 1500 ml of saliva secretion in a day.33. Caneschi WF, Paiva CCAN, Frade RL, Motta AR. Use of elastic bandage associated with speech therapy in the control of sialorrhea (hypersalivation). Rev CEFAC. 2014;16(5):1558-66. http://dx.doi.org/10.1590/1982-021620149813.
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However, there are several consequences of decreased salivary flow. These include some diseases and problems such as cavities, periodontal disease, various infections, dysphagia, halitosis and difficulties with the stability of dental prostheses.44. Flink H. Studies on the prevalence of reduced salivary flow rate in relation to general health and dental caries, and effect of iron supplementation. Swed Dent J Suppl. 2007;(192):3-50, 2 p preceding table of contents. PMID: 18274060.

Dry mouth syndrome or xerostomia is defined as decreased salivary flow or hypofunction of the salivary glands.55. Korn GP, Pupo DP, Quedas A, Bussoloti Filho I. Correlation between xerostomic level and the result of the sialometry in patients with Sjögren Syndrome. Rev Bras Otorrinolaringol. 2002;68(5):624-8. https://doi.org/10.1590/S0034-72992002000500004.
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Its origins are multicausal and might be the result of a change in the salivary glands or a systemic imbalance.55. Korn GP, Pupo DP, Quedas A, Bussoloti Filho I. Correlation between xerostomic level and the result of the sialometry in patients with Sjögren Syndrome. Rev Bras Otorrinolaringol. 2002;68(5):624-8. https://doi.org/10.1590/S0034-72992002000500004.
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,66. Freitas DN, Lock NC, Unfer B. Hipofunção das glândulas salivares em idosos hospitalizados relacionada a medicamentos [Salivary gland hypofunction in elderly people hospitalized related to drugs]. Revista Geriatria & Gerontologia. 2013;7(3):179-83. Available from: https://cdn.publisher.gn1.link/ggaging.com/pdf/v7n3a04.pdf . Accessed in 2021 (Mar 3).
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,77. Glore RJ, Spiteri-Staines K, Paleri V. A patient with dry mouth. Clin Otolaryngol. 2009;34(4):358-63. PMID: 19673984; https://doi.org/10.1111/j.1749-4486.2009.01930.x.
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Some determinants such as continuous use of medication, radiation, systemic diseases and factors common to aging might be associated with a dry mouth condition.88. Tanasiewicz M, Hildebrandt T, Obersztyn I. Xerostomia of Various Etiologies: A Review of the Literature. Adv Clin Exp Med. 2016;25(1):199-206. PMID: 26935515; https://doi.org/10.17219/acem/29375.
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Xerostomia is not considered to be a disease but, rather, a manifestation of a series of pathological conditions that considerably alter patients’ quality of life. It can affect chewing, swallowing, use of prostheses and speech.99. Ulloa BJP, Fredes CF. Manejo actual de la xerostomía. Rev. Otorrinolaringol. Cir. Cabeza Cuello. 2016;76(2):243-8. http://dx.doi.org/10.4067/S0718-48162016000200017.
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Villa et al. reported that xerostomia that is secondary to hyposalivation may also result in fungal infections such as candidiasis, tooth decay, halitosis, changes to the sense of taste and a burning sensation in the mouth.1010. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag. 2014;11:45-51. PMID: 25653532; https://doi.org/10.2147/TCRM.S76282.
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In addition, they reported that xerostomia may be a consequence of head and neck radiotherapy, depression, anxiety, stress and even malnutrition. It needs to be emphasized that some of the most common chronic conditions today are symptoms of depression and anxiety.1010. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag. 2014;11:45-51. PMID: 25653532; https://doi.org/10.2147/TCRM.S76282.
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There is some evidence that certain chronic diseases might be determinants of xerostomia and/or hyposalivation.1111. Siudikiene J, Machiulskiene V, Nyvad B, Tenovuo J, Nedzelskiene I. Dental caries and salivary status in children with type 1 diabetes mellitus, related to the metabolic control of the disease. Eur J Oral Sci. 2006;114(1):8-14. PMID: 16460335; https://doi.org/10.1111/j.1600-0722.2006.00277.x.
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,1212. Perotto JH, Andrades KMR, Paza AO, et al. Xerostomy prevalence related to medication on patients assisted by the dentistry area of the UNIVILLE. RSBO. 2007;4(2):16-9.,1313. Andrades KMR, Oliveira GB, Ávila LFC, Odebrecht MLR, Miguel LCM. Association of Glycemic Indexes, Hyposalivation, and Xerostomia Type 1 Diabetic Patients. Int J Odontostomat. 2011;5(2):185-90.,1414. López-Pintor RM, Casañas E, González-Serrano J, et al. Xerostomia, Hyposalivation, and Salivary Flow in Diabetes Patients. J Diabetes Res. 2016;2016:4372852. PMID: 27478847; https://doi.org/10.1155/2016/4372852.
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,1515. Lima DLF, Carneiro SDRM, Barbosa FTS, et al. Salivary flow and xerostomia in older patients with type 2 diabetes mellitus. PLoS One. 2017;12(8):e0180891. PMID: 28767676; https://doi.org/10.1371/journal.pone.0180891.
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One of the diseases most investigated today is diabetes mellitus (DM), a chronic disease characterized by hyperglycemia and insufficient insulin production by the pancreas.88. Tanasiewicz M, Hildebrandt T, Obersztyn I. Xerostomia of Various Etiologies: A Review of the Literature. Adv Clin Exp Med. 2016;25(1):199-206. PMID: 26935515; https://doi.org/10.17219/acem/29375.
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The insulin that is produced has the function of regulating carbohydrate metabolism, and its absence causes glucose to remain in the bloodstream, thus characterizing a state of hyperglycemia. Hyposalivation in patients with uncontrolled diabetes might be caused by an increase in diuresis, which could affect saliva production,1616. Wollner D. Oral implications of diabetes mellitus. Pac Health Dialog. 2003;10(1):98-101. PMID: 16276949. but it might also be caused by a condition called neuropathy.1717. Moore PA, Guggenheimer J, Etzel KR, Weyant RJ, Orchard T. Type 1 diabetes mellitus, xerostomia, and salivary flow rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92(3):281-91. PMID: 11552145; https://doi.org/10.1067/moe.2001.117815.
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,1818. Chavez EM, Taylor GW, Borrell LN, Ship JA. Salivary function and glycemic control in older persons with diabetes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(3):305-11. PMID: 10710454; https://doi.org/10.1016/s1079-2104(00)70093-x.
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,1919. Feio M, Sapeta P. Xerostomia em cuidados paliativos [Xerostomia in palliative care]. Acta Med Port. 2005;18(6):459-65. PMID: 16684486.,2020. do Amaral FM, Ramos PG, Ferreira SR. Estudo da freqüência de cárie e fatores associados no diabetes mellitus tipo 1 [Study on the frequency of caries and associated factors in type 1 diabetes mellitus]. Arq Bras Endocrinol Metabol. 2006;50(3):515-22. PMID: 16936993; https://doi.org/10.1590/s0004-27302006000300015.
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Therefore, there still seems to be much doubt concerning the cause-and-effect relationship between this pathological condition and xerostomia.2121. Shetty SR, Bhowmick S, Castelino R, Babu S. Drug induced xerostomia in elderly individuals: An institutional study. Contemp Clin Dent. 2012;3(2):173-5. PMID: 22919217; https://doi.org/10.4103/0976-237X.96821.
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In addition to correlations with chronic diseases, a relationship between xerostomia and use of continuous medication has been highlighted. Wiener et al.2222. Wiener RC, Wu B, Crout R, et al. Hipossalivação e xerostomia em idosos dentados. JADA. 2011;11(2):48-53. Available from: http://jada.ada.org/pb/assets/raw/Health%20Advance/journals/adaj/jada_port_mar_abr_2011_hipossalivacao.ashx.pdf . Accessed in 2021 (Mar 3).
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and Van der Putten et al.2323. van der Putten GJ, Brand HS, Schols JM, de Baat C. The diagnostic suitability of a xerostomia questionnaire and the association between xerostomia, hyposalivation and medication use in a group of nursing home residents. Clin Oral Investig. 2011;15(2):185-92. PMID: 20165967; https://doi.org/10.1007/s00784-010-0382-1.
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added anticholinergic, diuretic and antipsychotic drugs to the list of associated factors. Freitas et al.66. Freitas DN, Lock NC, Unfer B. Hipofunção das glândulas salivares em idosos hospitalizados relacionada a medicamentos [Salivary gland hypofunction in elderly people hospitalized related to drugs]. Revista Geriatria & Gerontologia. 2013;7(3):179-83. Available from: https://cdn.publisher.gn1.link/ggaging.com/pdf/v7n3a04.pdf . Accessed in 2021 (Mar 3).
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also included some types of analgesic and xerostomia-associated antibiotics.

Xerostomia is an important condition but is still little-known by the population and has been neglected by health professionals. In addition, studies on this condition are scarce and unenlightening. The absence of explanations about the determining factors of this condition can be highlighted, especially in relation to the non-institutionalized elderly population. The prevalence of xerostomia in the population has been reported to range from 5.5% to 46%.1010. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag. 2014;11:45-51. PMID: 25653532; https://doi.org/10.2147/TCRM.S76282.
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Gender and age-related differences have been observed, such that older individuals may have more symptoms of xerostomia. However, this could be due to the higher number of xerogenic drugs used to treat chronic diseases and might not only be related to age.1010. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag. 2014;11:45-51. PMID: 25653532; https://doi.org/10.2147/TCRM.S76282.
https://doi.org/https://doi.org/10.2147/...
,2121. Shetty SR, Bhowmick S, Castelino R, Babu S. Drug induced xerostomia in elderly individuals: An institutional study. Contemp Clin Dent. 2012;3(2):173-5. PMID: 22919217; https://doi.org/10.4103/0976-237X.96821.
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Nonetheless, these associations still seem unclear.

OBJECTIVE

Based on these scientific data, the objective of the present study was to ascertain the prevalence of self-reported xerostomia and to identify its association with chronic diseases, continuous medication use, age and gender, among elderly people in a municipality in southern Brazil.

The hypothesis for this study was that the presence of chronic systemic diseases and use of medications among the elderly people investigated would show associations with self-reported xerostomia.

METHODS

This study was submitted to and approved by the Research Ethics Committee of Faculdade Meridional (IMED), under the approval no. 2,711,544 and CAEE 90966718.0.0000.5319, on June 13, 2018, in accordance with the rules of resolution 466/12. All individuals participating in the research signed an informed consent statement in which they agreed to be part of it. Care was taken in this study to ensure confidentiality regarding identity and privacy, and also the confidentiality of the data obtained.

The present work was compiled in accordance with the recommendations of the STROBE statement (Strengthening the reporting of observational studies in epidemiology).2424. Malta M, Cardoso LO, Bastos FI, Magnanini MMF, Silva CMFP. STROBE Initiative: Subsidies for Reporting Observational Studies. Rev Saude Publica. 2010;44(3):559-65. https://doi.org/10.1590/S0034-89102010000300021.
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Design, sample and location of study

The present study took a quantitative approach, with a cross-sectional design. The study population consisted of the elderly population of the municipality of Vanini, which is located in the northwest of the state of Rio Grande do Sul. It has an estimated total population of 2,104 inhabitants and a total area of 69.9 km2.2525. IBGE. Instituto Brasileiro de Geografia e Estatística. Conheça o perfil das cidades brasileiras. Vanini. Available from: https://cidades.ibge.gov.br/brasil/rs/vanini/panorama. Accessed in 2021 (Mar 3).
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The population of Vanini over 60 years of age consisted of 300 people.2525. IBGE. Instituto Brasileiro de Geografia e Estatística. Conheça o perfil das cidades brasileiras. Vanini. Available from: https://cidades.ibge.gov.br/brasil/rs/vanini/panorama. Accessed in 2021 (Mar 3).
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All of this population was eligible, but seven people were excluded from the study (see criteria, below). Thus, the study population was formed by 293 elderly people aged 60 years and over. There were no losses in this study.

Inclusion and exclusion criteria

All the elderly population aged 60 years and over participated in this study. Only those with neurological conditions and patients with head and neck cancers undergoing radiotherapy were excluded from the study.

Data collection procedures

Data collection was performed through home visits to all houses in the municipality, made by a team composed of four students of the dentistry course, between August and September 2018. First, a pilot test was performed on twenty elderly people in order to train the researchers to collect data and to check for possible doubts or problems relating to completion of the research instrument by the elderly subjects, thus minimizing possible bias in the research methodology. However, there were no changes to the procedures and, later on, these data from the pilot study were included in the final sample.

The data relating to the variable of self-reported xerostomia were collected by means of a validated questionnaire for xerostomia and dry mouth sensation that is used to verify cases of self-reported xerostomia. The Xerostomia Inventory (XI) includes eleven items.2626. Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The Xerostomia Inventory: a multi-item approach to measuring dry mouth. Community Dent Health. 1999;16(1):12-7. PMID: 10697349. A previous study validated this questionnaire for use among Brazilian individuals.2727. da Mata AD, da Silva Marques DN, et al. Translation, validation, and construct reliability of a Portuguese version of the Xerostomia Inventory. Oral Dis. 2012;18(3):293-8. PMID: 22151408; https://doi.org/10.1111/j.1601-0825.2011.01879.x.
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Each item in this questionnaire has five response options: never, hardly ever, occasionally, fairly often and very often. The questions are the following: “Do you have difficulties swallowing any foods?”, “Do you have difficulties eating dry foods?”, “Does your mouth feel dry when eating a meal?”, “Does your nose feel dry?”, “Does your face feel dry?”, “Do you suck sweets or cough lollies to relieve dry mouth?”, “Do you get up at night to drink?”, “Do your eyes feel dry?”, “Do your lips feel dry?”, “Does your mouth feel dry?” and “Do you sip liquids to aid in swallowing food?”,

We added questions asking for demographic data (gender and age) and questions asking about chronic diseases and continuous medication use, consisting of the following: “Do you use continuous medications?”, “Do you have diabetes, thyroid dysfunction, rheumatoid arthritis, depression and/or anxiety, HIV, hypertension and/or any other diseases?” and “Do you use medications for the stomach, cholesterol or diuretics, or do you use anticoagulants?” In addition, we also included a question on “Difficulty in using a dental prosthesis”.

Outcome variable

We composed the outcome variable of this study based on studies conducted by Thomson et al. in 19992626. Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The Xerostomia Inventory: a multi-item approach to measuring dry mouth. Community Dent Health. 1999;16(1):12-7. PMID: 10697349. and 2006,2828. Murray Thomson W, Poulton R, Mark Broadbent J, Al-Kubaisy S. Xerostomia and medications among 32-year-olds. Acta Odontol Scand. 2006;64(4):249-54. PMID: 16829502; https://doi.org/10.1080/00016350600633243.
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which used a single question from the XI questionnaire to ascertain the prevalence of xerostomia. In the present study, we did not perform an oral clinical evaluation.

We combined the responses to the questions of the XI questionnaire into negative answers (no) = never, hardly never and occasionally; and positive answers (yes) = fairly often and very often. Thus, people who answered positively to the XI question “My mouth feels dry” were included in the self-reported xerostomia group.2828. Murray Thomson W, Poulton R, Mark Broadbent J, Al-Kubaisy S. Xerostomia and medications among 32-year-olds. Acta Odontol Scand. 2006;64(4):249-54. PMID: 16829502; https://doi.org/10.1080/00016350600633243.
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Covariables

The variables considered were gender (female or male), age (60 to 69 years old or 70 years old or over), diabetes (yes/no), thyroid dysfunction (yes/no), rheumatoid arthritis (yes/no), depression and/or anxiety (yes/no), arterial hypertension (yes/no), HIV (yes/no), other chronic diseases and continuous medication (yes/no), use of medicine for cholesterol (yes/no), use of gastrointestinal tract medication (yes/no), use of diuretic (yes/no), use of anticoagulants (yes/no) and difficulty in using a dental prosthesis (yes/no).

The variable “other chronic diseases and continuous medication” (yes/no) was composed of diseases other than the most prevalent diseases mentioned previously and was considered together with use of drugs to control these diseases. This formed a reliable way of knowing whether the elderly individual was being medicated. The diseases included in this variable were fibromyalgia, Parkinson’s disease, hypothyroidism, osteoporosis, cardiac arrhythmia and multiple sclerosis.

Data analysis

For the data analysis, we performed descriptive analyses and bivariate and multiple regressions. In the multiple analysis, we estimated odds ratios (OR) and their respective 95% confidence intervals, with crude variables and variables adjusted for exposure in binary logistic regression models (P-value < 0.05). The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 20.0 (IBM, Armonk, New York, United States).

RESULTS

Table 1 describes the results regarding demographic variables, chronic diseases, difficulties and use of continuous medications. Most of the elderly people were between 60 and 69 years old, and a majority of the population (56%) was male.

Table 1.
Description of demographic variables, chronic diseases and use of continuous medications among elderly people in the municipality of Vanini, Brazil, 2019 (n = 293)

Among these elderly people, 12.6% presented diabetes; 10.2%, diseases relating to thyroid dysfunction; 23.2%, depression and anxiety; 57%, arterial hypertension; and 10.2%, rheumatoid arthritis. Moreover, 40.3% of them reported having other diseases, i.e. in addition to those being researched in this study. Thus, in addition to the medications used for the chronic diseases that they reported (diabetes, thyroid dysfunction, rheumatoid arthritis, depression and anxiety, HIV and hypertension), they also used cholesterol-lowering drugs (27%) and medicines for stomach and circulatory problems (17.1%). These elderly people also had other chronic diseases and used continuous medications for their control (40.3%).

Table 2 shows the results relating to Xerostomia Inventory (XI) variables. Presence of dry mouth sensation was reported by 19.1% of the participants when asked the question “Does your mouth feel dry?” Furthermore, 13.3% had difficulty in swallowing food, 14.7% sipped liquids to aid in swallowing food and 30.4% habitually got up at night to drink. In the question about having difficulty in using a dental prosthesis, only 2% of the elderly people answered yes; however, 100% of them were using some type of dental prosthesis.

Table 2.
Distribution of responses to questions regarding dry mouth (xerostomia) from the Xerostomia Inventory (XI), among elderly people in the municipality of Vanini, Brazil, 2019 (n = 293)

To perform the binary logistic regression, all variables that had an association with a P-value < 0.20 were entered into the crude model: gender, depression or anxiety, diabetes, other chronic diseases with continuous medication, gastrointestinal tract medication, cholesterol drugs and use of anticoagulants. After multivariate adjustment, the variables of diabetes, other chronic diseases and gastrointestinal tract medication remained significant (P < 0.05), but the other variables lost their associations in the final adjusted multivariate regression analysis model (Table 3). Elderly people with diabetes had higher odds of having self-reported xerostomia (OR: 3.59; 95% CI: 1.48-8.68; P < 0.001), as did those who had chronic diseases and used continuous medication (OR: 2.3; 95% CI: 1.19-4.67; P = 0.009). The elderly people who continuously used medication for the gastrointestinal tract also had higher odds of having xerostomia (OR: 2.14; 95% CI: 1.03-1.44; P = 0.030).

Table 3.
Bivariate (crude) and multivariate (adjusted) binary logistic regression model for the self-reported xerostomia variable, among elderly people in the municipality of Vanini, Brazil, 2019

DISCUSSION

The purpose of this study was to ascertain the prevalence of self-reported xerostomia and to identify its associations with chronic diseases, continuous medication use, age and gender, among the elderly, in order to learn about these data, which had never been investigated in this location. The results showed that the prevalence of self-reported xerostomia was 19.1%, through using the XI question “Does your mouth feel dry?”. It is also important to point out that 13% reported feeling “difficulties in swallowing certain foods” and 14.7% “sipped liquids to aid in swallowing food”, which are important responses for indicating the presence of xerostomia. Xerostomia is a subjective sensation of dry mouth and is assessed by asking individuals directly about their experience with this disease. According to other studies, the question “ Does your mouth feel dry” reveals the prevalence of dry mouth.2626. Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The Xerostomia Inventory: a multi-item approach to measuring dry mouth. Community Dent Health. 1999;16(1):12-7. PMID: 10697349.,2828. Murray Thomson W, Poulton R, Mark Broadbent J, Al-Kubaisy S. Xerostomia and medications among 32-year-olds. Acta Odontol Scand. 2006;64(4):249-54. PMID: 16829502; https://doi.org/10.1080/00016350600633243.
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Thus, salivary flow was not measured in this study. Dry mouth is an important condition that negatively impacts people’s daily lives, so the results presented here should be considered with caution.

The study conducted by Thomson et al. among adults and the elderly showed that the prevalence of xerostomia was 10%, with no difference between the genders.2828. Murray Thomson W, Poulton R, Mark Broadbent J, Al-Kubaisy S. Xerostomia and medications among 32-year-olds. Acta Odontol Scand. 2006;64(4):249-54. PMID: 16829502; https://doi.org/10.1080/00016350600633243.
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Perotto et al.1212. Perotto JH, Andrades KMR, Paza AO, et al. Xerostomy prevalence related to medication on patients assisted by the dentistry area of the UNIVILLE. RSBO. 2007;4(2):16-9. evaluated 117 dental patients, among whom 24.8% reported having xerostomia, which was associated with medication use. This differed from the results found by Freitas et al.,66. Freitas DN, Lock NC, Unfer B. Hipofunção das glândulas salivares em idosos hospitalizados relacionada a medicamentos [Salivary gland hypofunction in elderly people hospitalized related to drugs]. Revista Geriatria & Gerontologia. 2013;7(3):179-83. Available from: https://cdn.publisher.gn1.link/ggaging.com/pdf/v7n3a04.pdf . Accessed in 2021 (Mar 3).
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in which 59% of the elderly subjects reported having a feeling of dry mouth during most of the day, and this sensation was associated with the medication that they were using. The estimated global prevalence of dry mouth was found to be 22% among adult and elderly individuals in a systematic review study.2929. Agostini BA, Cericato GO, Silveira ERD, et al. How Common is Dry Mouth? Systematic Review and Meta-Regression Analysis of Prevalence Estimates. Braz Dent J. 2018;29(6):606-18. PMID: 30517485; https://doi.org/10.1590/0103-6440201802302.
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However, the prevalence was higher in studies conducted exclusively among elderly people, and presence of xerostomia in these studies was correlated with older age and the need for continuous-use drugs with high xerostomic potential, among which most were used to treat chronic diseases.2929. Agostini BA, Cericato GO, Silveira ERD, et al. How Common is Dry Mouth? Systematic Review and Meta-Regression Analysis of Prevalence Estimates. Braz Dent J. 2018;29(6):606-18. PMID: 30517485; https://doi.org/10.1590/0103-6440201802302.
https://doi.org/https://doi.org/10.1590/...

In a study conducted by Islas-Granillo et al.,3030. Islas-Granillo H, Borges-Yáñez A, Fernández-Barrera MÁ, et al. Relationship of hyposalivation and xerostomia in Mexican elderly with socioeconomic, sociodemographic and dental factors. Sci Rep. 2017 Jan 17;7:40686. PMID: 28094800; https://doi.org/10.1038/srep40686.
https://doi.org/https://doi.org/10.1038/...
68.3% of the elderly subjects had xerostomia. Niklander et al.,3131. Niklander S, Veas L, Barrera C, et al. Risk factors, hyposalivation and impact of xerostomia on oral health-related quality of life. Braz Oral Res. 2017;31:e14. PMID: 28099580; https://doi.org/10.1590/1807-3107BOR-2017.vol31.0014.
https://doi.org/https://doi.org/10.1590/...
in a survey on 566 individuals, observed that 42.4% of them took some type of medication and, of these, 17.92% reported having dry mouth. According to Lopes et al.,3232. Lopes FF, Silva LFG, Carvalho FL, et al. Estudo sobre xerostomia, fluxo salivar e enfermidades sistêmicas em mulheres na pós-menopausa [Study about xerostomia, salivary flow rate and systemic conditions of postmenopausal women]. RGO. 2008;56(2):127-30. out of 20 women surveyed, 50% reported having xerostomia. Another study, conducted by Wiener et al.,2222. Wiener RC, Wu B, Crout R, et al. Hipossalivação e xerostomia em idosos dentados. JADA. 2011;11(2):48-53. Available from: http://jada.ada.org/pb/assets/raw/Health%20Advance/journals/adaj/jada_port_mar_abr_2011_hipossalivacao.ashx.pdf . Accessed in 2021 (Mar 3).
http://jada.ada.org/pb/assets/raw/Health...
showed that among 252 elderly individuals surveyed, 28% had xerostomia associated with sociodemographic conditions, medication use and systemic conditions. The complaint of dry mouth needs to be taken seriously by healthcare professionals and, thus, individuals with this complaint should be asked about what they feel, their medical history and the medicines that they are taking, considering that indefinite-cause xerostomia is an undiagnosed systemic imbalance.

In the present study, there was a statistically significant association between self-reported xerostomia and presence of the chronic disease diabetes mellitus. The chances that an individual with DM who uses continuous medication for this condition will have xerostomia or dry mouth are 3.59 times higher than among other elderly people. It should be noted that all the elderly people in the present study were using medication at the time of data collection.

In another study, presence of xerostomia among patients with decompensated DM was explained by increased diuresis or polyuria, which could affect saliva production.1313. Andrades KMR, Oliveira GB, Ávila LFC, Odebrecht MLR, Miguel LCM. Association of Glycemic Indexes, Hyposalivation, and Xerostomia Type 1 Diabetic Patients. Int J Odontostomat. 2011;5(2):185-90. Carda et al.3333. Carda C, Mosquera-Lloreda N, Salom L, et al. Structural and functional salivary disorders in type 2 diabetic patients. Med Oral Patol Oral Cir Bucal. 2006;11(4):E309-14. PMID: 16816810. surveyed 33 patients with type 2 DM and found that 76.4% of them had symptoms of xerostomia. However, it has been reported that it remains undetermined whether the presence of xerostomia is higher in patients with or without diabetes.1414. López-Pintor RM, Casañas E, González-Serrano J, et al. Xerostomia, Hyposalivation, and Salivary Flow in Diabetes Patients. J Diabetes Res. 2016;2016:4372852. PMID: 27478847; https://doi.org/10.1155/2016/4372852.
https://doi.org/https://doi.org/10.1155/...
In a further study, the prevalence of xerostomia among 120 elderly people diagnosed with type 2 diabetes (60 insulin-dependent individuals and 60 who did not require it) who had been undergoing treatment for at least one year using continuous medication was surveyed. Dry mouth or xerostomia was evaluated on a visual analogue scale. Among these patients, 92.5% presented hyposalivation and 49.2% had moderate to severe dry mouth or xerostomia.1515. Lima DLF, Carneiro SDRM, Barbosa FTS, et al. Salivary flow and xerostomia in older patients with type 2 diabetes mellitus. PLoS One. 2017;12(8):e0180891. PMID: 28767676; https://doi.org/10.1371/journal.pone.0180891.
https://doi.org/https://doi.org/10.1371/...

Although the present study did not show any significant relationships with depression and anxiety, high blood pressure or thyroid dysfunction, several other studies have highlighted this association. Thomson et al.2828. Murray Thomson W, Poulton R, Mark Broadbent J, Al-Kubaisy S. Xerostomia and medications among 32-year-olds. Acta Odontol Scand. 2006;64(4):249-54. PMID: 16829502; https://doi.org/10.1080/00016350600633243.
https://doi.org/https://doi.org/10.1080/...
found relationships between xerostomia and the use of antidepressants, iron supplements and analgesics. The complaint of dry mouth was more frequent among adults who were using antidepressants, and also among those using other medications such as iron and narcotic painkillers. The individuals who were taking antidepressants were 22 times more likely to feel dry mouth or proper xerostomia.2828. Murray Thomson W, Poulton R, Mark Broadbent J, Al-Kubaisy S. Xerostomia and medications among 32-year-olds. Acta Odontol Scand. 2006;64(4):249-54. PMID: 16829502; https://doi.org/10.1080/00016350600633243.
https://doi.org/https://doi.org/10.1080/...
Perotto et al.1212. Perotto JH, Andrades KMR, Paza AO, et al. Xerostomy prevalence related to medication on patients assisted by the dentistry area of the UNIVILLE. RSBO. 2007;4(2):16-9. observed other predisposing factors for xerostomia, consisting of age 50 years and over and presence of diabetes and hypertension.

A study by Bulthuis et al.3434. Bulthuis MS, Jan Jager DH, Brand HS. Relationship among perceived stress, xerostomia, and salivary flow rate in patients visiting a saliva clinic. Clin Oral Investig. 2018;22(9):3121-7. PMID: 29520470; https://doi.org/10.1007/s00784-018-2393-2.
https://doi.org/https://doi.org/10.1007/...
estimating the possible role of stress in salivary secretion showed a correlation between stress and xerostomia, and it was concluded that stress was related to dry mouth sensation and consequently had an impact on quality of life. A study among adults showed a strong association between xerostomia and quality of life.3535. Thomson WM, Ibrahim H, Lyons KM, Foster Page LA, Hanlin SM. Personality, xerostomia and OHRQoL among 35-54-year-olds. Acta Odontol Scand. 2019;77(2):114-8. PMID: 30623711; https://doi.org/10.1080/00016357.2018.1510138.
https://doi.org/https://doi.org/10.1080/...
According to Abrão et al.,3636. Abrão ALP, Santana CM, Bezerra ACB, et al. What rheumatologists should know about orofacial manifestations of autoimmune rheumatic diseases. Rev Bras de Reumatol. 2016;56(5):441-50. http://dx.doi.org/10.1016/j.rbre.2016.02.006.
https://doi.org/http://dx.doi.org/10.101...
alterations such as xerostomia and hyposalivation are common in rheumatic diseases, such that xerostomia affects 1% of patients with rheumatoid arthritis. That study evaluated 604 patients with rheumatological disorders and showed that 43% of them had hyposalivation; this hyposalivation and dry mouth/xerostomia increased with increasing severity of the rheumatological condition.3636. Abrão ALP, Santana CM, Bezerra ACB, et al. What rheumatologists should know about orofacial manifestations of autoimmune rheumatic diseases. Rev Bras de Reumatol. 2016;56(5):441-50. http://dx.doi.org/10.1016/j.rbre.2016.02.006.
https://doi.org/http://dx.doi.org/10.101...

In the present study, there was an association with the presence of other chronic diseases in the survey questionnaire and their continuous medication. These elderly individuals were 2.3 more likely to have self-reported xerostomia, with a prevalence of 42%. Thus, it can be inferred that, in addition to chronic diseases, the continuous medication itself might have been the cause of these results. Korn et al.55. Korn GP, Pupo DP, Quedas A, Bussoloti Filho I. Correlation between xerostomic level and the result of the sialometry in patients with Sjögren Syndrome. Rev Bras Otorrinolaringol. 2002;68(5):624-8. https://doi.org/10.1590/S0034-72992002000500004.
https://doi.org/https://doi.org/10.1590/...
observed that various systemic disorders could cause xerostomia or the feeling of dry mouth, among them Sjögren’s syndrome. Regarding the results from the present study, it is important to stress that the amount of medication used by the elderly individuals was not investigated, given that there could have been significant differences relating, not to other diseases, but to the higher number of drugs used to treat different chronic illnesses.55. Korn GP, Pupo DP, Quedas A, Bussoloti Filho I. Correlation between xerostomic level and the result of the sialometry in patients with Sjögren Syndrome. Rev Bras Otorrinolaringol. 2002;68(5):624-8. https://doi.org/10.1590/S0034-72992002000500004.
https://doi.org/https://doi.org/10.1590/...

Chronic diseases are the ones that most affect the elderly, and they lead to use of large-scale continuous medication.3737. Rigo L, Garbin RR, Rodrigues JLSA, et al. Self-perceived quality of health and satisfaction by elderly seen by the Family Health Strategy team. Einstein (Sao Paulo). 2017;15(4):428-34. PMID: 29364365; https://doi.org/10.1590/S1679-45082017AO3972.
https://doi.org/https://doi.org/10.1590/...
In addition to medications for diabetes, depression and anxiety, others can be considered, such as medications for cardiovascular diseases, nervous system disorders, gastrointestinal tract diseases and metabolic disorders. Therefore, there is an interaction of factors that might cause dry mouth sensation or hyposalivation. In addition to the chronic diseases already mentioned, some drugs could cause xerostomia as a side effect of the treatment.

In the present study, there was a statistically significant association between medication for the gastrointestinal tract and xerostomia. The elderly individuals who used continuous medication for the gastrointestinal tract were 2.14 times more likely to have the condition of xerostomia (28.6%). A study to assess the side effects of several drugs showed an association between the presence of xerostomia and a digestive tract drug called ondansetron.66. Freitas DN, Lock NC, Unfer B. Hipofunção das glândulas salivares em idosos hospitalizados relacionada a medicamentos [Salivary gland hypofunction in elderly people hospitalized related to drugs]. Revista Geriatria & Gerontologia. 2013;7(3):179-83. Available from: https://cdn.publisher.gn1.link/ggaging.com/pdf/v7n3a04.pdf . Accessed in 2021 (Mar 3).
https://cdn.publisher.gn1.link/ggaging.c...
However, it has been reported that medications that cause dry mouth sensation could mainly be those with antisialogogic effects, including anticholinergics, antidepressants, diuretics, antihypertensives, antipsychotics and anxiolytics.2222. Wiener RC, Wu B, Crout R, et al. Hipossalivação e xerostomia em idosos dentados. JADA. 2011;11(2):48-53. Available from: http://jada.ada.org/pb/assets/raw/Health%20Advance/journals/adaj/jada_port_mar_abr_2011_hipossalivacao.ashx.pdf . Accessed in 2021 (Mar 3).
http://jada.ada.org/pb/assets/raw/Health...

In another study, dry mouth sensation was correlated with the drugs used. It was observed that 11 out of 20 medications used by the elderly subjects had side effects of xerostomia and/or hypofunction of the salivary glands, namely: dipyrone, clonazepam, morphine, ondansetron, enalapril, clonidine, metronidazole, tramadol, clindamycin, diazepam and fluoxetine.66. Freitas DN, Lock NC, Unfer B. Hipofunção das glândulas salivares em idosos hospitalizados relacionada a medicamentos [Salivary gland hypofunction in elderly people hospitalized related to drugs]. Revista Geriatria & Gerontologia. 2013;7(3):179-83. Available from: https://cdn.publisher.gn1.link/ggaging.com/pdf/v7n3a04.pdf . Accessed in 2021 (Mar 3).
https://cdn.publisher.gn1.link/ggaging.c...
Similar results were found in a study by Van Der Putten,2323. van der Putten GJ, Brand HS, Schols JM, de Baat C. The diagnostic suitability of a xerostomia questionnaire and the association between xerostomia, hyposalivation and medication use in a group of nursing home residents. Clin Oral Investig. 2011;15(2):185-92. PMID: 20165967; https://doi.org/10.1007/s00784-010-0382-1.
https://doi.org/https://doi.org/10.1007/...
in which the medications that could be the cause of dry mouth sensation or xerostomia were investigated, namely: anticholinergics, antihistamines, antipsychotics, diuretics, sympathomimetics, bronchodilators, benzodiazepines, hypnotics, opioid analgesics, muscle relaxants and antidepressants. According to Perotto et al.,1212. Perotto JH, Andrades KMR, Paza AO, et al. Xerostomy prevalence related to medication on patients assisted by the dentistry area of the UNIVILLE. RSBO. 2007;4(2):16-9. the symptoms of xerostomia occurred in individuals using antidepressants, anticonvulsants and antihypertensives. According to Villa et al.,1010. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag. 2014;11:45-51. PMID: 25653532; https://doi.org/10.2147/TCRM.S76282.
https://doi.org/https://doi.org/10.2147/...
the main cause of hyposalivation and/or xerostomia was the use of medications that included antidepressants, antihypertensives, anticoagulants, antiretrovirals, levothyroxine, supplements and multivitamins, hypoglycemics, steroid inhalers and non-steroidal anti-inflammatory drugs.

It needs to be borne in mind, as a limitation of the present study, that its design was cross-sectional and therefore cause and effect could not be verified, considering that data were analyzed at a single moment. Another limitation that needs to be acknowledged is the fact that memory bias is possible among elderly people when they answer questions. In addition, the variable “chronic diseases and continuous use of medicines” was very broad. Nonetheless, this formed a way of including other diseases and the medicines indicated for their control. Furthermore, this study did not identify risk factors for the self-reported xerostomia analyzed here. If we had been able to evaluate long-term reports on these individuals and their salivary levels, it might have been possible to observe the incidence and factors that could interfere with this condition. Another limitation was the fact that the municipality analyzed is small and we cannot extrapolate the results to other municipalities that are not similar to this one. However, it is important to highlight that the entire population aged 60 years and over that was living in this location participated in this research.

Knowing the causes of xerostomia from self-reports given by the participants in this study will enable implementation of guidance interventions to improve these individuals’ quality of life. However, the data on causality remains uncertain and more information is required in order to be able to reach conclusions regarding the determinants of xerostomia. Nonetheless, the present study is of great relevance and importance for the population surveyed, given that it provides real current data on the elderly people living in this municipality.

CONCLUSIONS

From the results we obtained in this study, it was possible to conclude that the prevalence of self-reported xerostomia among the elderly people in this municipality is moderate, which corroborates the findings in the literature.

Elderly people with diabetes and other chronic diseases using continuous medications are more likely to have dry mouth. Use of continuous medications for the gastrointestinal tract gives rise to a greater chance of having self-reported xerostomia among elderly people.

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  • 1
    Faculdade Meridional (IMED), Passo Fundo (RS), Brazil
  • Sources of funding: None

Publication Dates

  • Publication in this collection
    25 June 2021
  • Date of issue
    Jul-Aug 2021

History

  • Received
    15 Oct 2020
  • Reviewed
    17 Feb 2021
  • Accepted
    19 Feb 2021
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