Relieving dry mouth from type 2 diabetes and other causes

Relation

Badooie F, Imani E, Hosseini-Teshnizi S, et al. Comparison of the effect of ginger and aloe vera mouthwashes on xerostomia in patients with type 2 diabetes: a clinical trial, triple-blind.Med Oral Patol Oral Cir Bucal.2021;26(4):e408-e413.

Study objective

To determine and compare the benefits of ginger, aloe vera, and normal saline mouthwashes for the relief of xerostomia in patients with type 2 diabetes

Draft

A triple-blind study

Participant

Investigators enrolled 105 participants and then divided them into 3 groups of 35. All participants were diagnosed with type 2 diabetes and xerostomia based on the scale by Fox et al. and visual analogue scale (VAS), and they agreed to participate in the study.

The normal saline group consisted of 17 men and 18 women, aged 58.13 ± 14.75 years. The aloe vera group consisted of 11 men and 24 women aged 53.37 ± 11.57 years. The ginger group consisted of 15 men and 20 women aged 54.14 ± 9.35 years.

Exclusion criteria included the presence of oral ulcers or infections, excessive physical activity, use of mouthwashes or saliva substitutes, physical or mental limitations, or migration considerations.

intervention

Participants received 20 mL of either 25% ginger, 50% aloe vera, or normal saline (control). Participants were asked to hold the solution in their mouth for 1 minute and then cough it up three times daily for 14 days. The investigators assessed the presence of xerostomia before and after the study using a method developed by Fox et al. developed 10-question survey in which the participant answers yes or no and a linear VAS from 0 to 100.

Study parameters assessed

The study evaluated the improvement in the subjective feeling of xerostomia, reflected in a lower total score from the Fox questionnaire and a linear decrease in the VAS.

Primary outcome measure

Difference in the pre- and post-intervention total score from the Fox questionnaire validated with changes in the VAS, with a decrease indicating an improvement in the subjective feeling of xerostomia.

Key insights

All 3 groups achieved a statistically significant improvement in xerostomia (P<0.001). The ginger group had the highest reduction in total score (VAS2 – VAS1 = −6.12 ± 2.004 cm); followed by the aloe vera group (−4.08 ± 2.09 cm) and the saline group (−2.48 ± 2.09 cm).

Practice implications

The authors point out that xerostomia, a subjective feeling of dry mouth, occurs in up to 80% of diabetics, but failed to draw attention to many other causes of xerostomia, including taking many medications, taking nutritional supplements, psychological factors, Sjögren's syndrome, rheumatoid arthritis, lupus erythematosus, scleroderma, hypothyroidism, head and neck irradiation and salivary gland disease.^1.2With such prevalence, together with an apparent increase in autoimmune diseases of all kinds, it would be appropriate for all practitioners to be aware of the difficulties faced by patients suffering from subjective symptoms of dry mouth. In fact, an article by Deepak Daryani rates xerostomia as the fourth most distressing symptom known.³

The authors discuss the possible consequences of xerostomia, including oral infections, accumulating bacteria that can become systemic, fungal infections, respiratory diseases, and cardiovascular effects. Possible complications associated with xerostomia include difficulty speaking, swallowing, or tasting food, and the inability to hold dentures. These are quite serious effects, all of which affect the quality of life.

While several objective means of determining salivary flow rate have been implemented, these are more relevant to hyposalivation, which is a decrease in salivary flow from a normal unstimulated flow rate of 0.3 to 0.4 mL/min to 0.1 mL/min or less.¹These measurements are quite cumbersome and time-consuming and are best suited for investigative purposes. A more pragmatic approach may be to use a questionnaire developed by Sreebny and Valdini in which the patient is asked a question: “Does your mouth usually feel dry?” This 1 question showed a sensitivity of 93%, a specificity of 68%, a positive predictive value of 54%, and a negative predictive value of 98%. The addition of 3 related conditions (difficulty speaking, trying to keep mouth moist, and getting out of bed to drink) increased the specificity to 91% and the positive predictive value to 75%.²

The addition of clinical signs certainly helps in the diagnosis of xerostomia. Osailan et al. presented and confirmed some of these clinical signs, including: a mouth mirror or tongue depressor adhered to the buccal mucosa or tongue, foamy saliva, lack of saliva accumulation in the floor of the mouth, loss of papillae on the back of the tongue, altered gingival architecture, glassy appearance of the oral mucosa, lobed or torn tongue, more than 2 teeth with cervical caries and Mucosal debris on the palate.⁴

Possible complications associated with xerostomia include difficulty speaking, swallowing, or tasting food, and the inability to hold dentures.

The use of aloe vera and ginger to treat xerostomia has already been studied and their effectiveness is well documented. What was interesting about this study was the choice of normal saline for use in the control group. Of course, this seems contradictory, since the osmotic action of the sodium chloride should draw fluid out of the mucous membrane, only to be spit out, leading to a worsening of the condition. However, the results of the study indicate a reduction in overall Fox and VAS scores, that is, an improvement. So what gives? An answer can be found in the study conducted by Deepak Daryani and Gopakmar R., where they found that the saliva of xerostomia patients contained more than three times more sodium and more than two times more chloride than control patients' saliva.³Thus, water from the normal saline solution would be drawn into the mucosal tissue and moisten it. It is unknown whether the authors were aware of this finding, and if so, other controls could have been considered.

So it's no wonder that frequent drinking of water is the number 1 home remedy for xerostomia patients.⁵However, water has the same limitation as saliva substitutes and other liquids used to relieve xerostomia symptoms, and that is the time of action, which is usually less than 15 minutes. This limitation explains why most patients prefer gels to liquids or sprays.⁶Lozenges such as lemon drops are considered salivary stimulators, but they only work if the salivary glands are functioning normally, which is unfortunately not the case for many patients. This also applies to pharmacological stimulants such as pilocarpine, which are associated with possible unpleasant side effects.

The literature is robust with various natural products proven effective in relieving the symptoms of xerostomia including, but not limited to: milk, olive oil, canola oil, linseed oil, sesame oil, yam mucilage, marshmallow root, honey, propolis, chamomile,Marigold officinalisPeppermint, essential oils and of course aloe vera and ginger.^7.8

Aloe vera and ginger are excellent treatment options. They are familiar, readily available, and have well-known safety profiles. Both have antibacterial, antiviral, antifungal, antioxidant and immune-modulating effects.^9.10Both show an antimicrobial effect againstS mutansandLactobacillissp,^10,11which are the primary pathogens that cause dental caries.¹²They are effective againstCandida albicans^10,13and have proven to be just as effective against periodontitis as chlorhexidine.^14.15Ginger is known to stimulate saliva secretion when taken both systemically and topically.10 Aloe vera contains a sticky polysaccharide, acemannan, which increases its effectiveness and aids in retaining braces.⁹

While the authors provide no information about how the participants were blinded to the solution they received, one has to wonder how they disguised the different flavors of aloe vera, ginger, and normal saline. The authors did not explain what effect using an essential oil such as peppermint or spearmint would have had. However, the use of ginger and aloe vera have been proven effective and we should include them in our arsenal of treatment options for xerostomia patients.

Interestingly, ginger with rosemary in gel form or ginger, natural honey and dark chocolate have been shown to remineralize tooth enamel just as effectively as fluoride.^16,17