Assessment of xerostomia in general population: A questionnaire study as a screening tool for hyposalivation

INTRODUCTION

Hyposalivation is a reduced salivary flow that may result from a variety of extrinsic stimuli as well as natural changes.^[1] Those who are affected by this condition may or may not experience the “dry mouth” (xerostomia) sensation. Both xerostomia and hyposalivation can arise independently, although xerostomia is typically a sign of hyposalivation because it is caused by a decrease in salivary secretion.^[2]

Hyposalivation and xerostomia can be caused by a variety of disorders, from transient variables like stress and anxiety to autoimmune diseases and long-term ailments including rheumatoid arthritis, Parkinson’s disease, Sjogren’s syndrome, and diabetes mellitus.^[3] The two conditions may also be found in patients requiring treatment for head-and-neck cancer and those with diseases specific to the salivary glands.^[4] Hyposalivation is diagnosed through sialometry, a procedure that involves collecting saliva to determine the rate of salivary secretion per minute.^[5]

Hyposalivation must be diagnosed since it can have a detrimental effect on everyday activities and quality of life.^[6] An increased incidence of oral infectious diseases and disorders, such as caries and candidiasis, is another effect of hyposalivation.^[7]

Hyposalivation combined with a weakened immune system promotes oral infections including dental caries because of plaque accumulation and saliva’s insufficient ability to act as a buffer.^[8] Disruptions in the balance of the oral microbiota can contribute to the development of fungal infections, with candidiasis being the most common manifestation.^[7]

MATERIAL AND METHODS

Data collection

Initially, approval was obtained from the Institutional Ethics Committee. Instructions related to the study procedure and counseling of all the participants, regarding stimulation of salivary flow were given. Participants also underwent a medical examination to identify any underlying systemic conditions potentially linked to hyposalivation.

Data were recorded based on the age and gender of the participants. Out of 200, a total of 173 participants reported for testing. They were provided with the modified xerostomia questionnaire proposed by Nunes et al.,^[9] based on Torres et al.’s work [Supplementary Material].^[10]

Supplementary Material

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Stimulated salivary flow was collected between 8:30 and 10:30 am in a quiet room. Participants were asked to chew a parafilm tablet (1.5 cm × 1.5 cm) to stimulate saliva production. After swallowing the initial saliva, participants were instructed to continuously expectorate into a beaker over a period of 5 min. The collected saliva was assessed for salivary flow using a glass test tube, with a flow rate of <0.7 mL/min considered indicative of hyposalivation.^[11]

The following are the photographs showing:

1. Patient was filling questionnaire form before and after the saliva collection [Figure 1a]

2. Saliva was collected in a beaker for 5 min [Figure 1b]

3. Collected saliva was measured in a test tube [Figure 1c].

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Figure 1:

(a) Participant completing xerostomia questionnaire, (b) Collection of stimulated saliva over 5 minutes, (c) Measurement of saliva using graduated test tube.

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RESULTS

The number of responses of all the participants is mentioned in [Tables 1 and 2]. The descriptive statistics show that the sample has 173 individuals aged between 36 and 80, with an average age of 56.32 years. The gender distribution indicates that 43.9% (n = 76) of the participants were female and 56.1% (n = 97) were male (Software Used: IBM Statistical Package for the Social Sciences Statistics 20). Table 3 presents the association between the clinical diagnosis of hyposalivation and various questionnaire items. Significant associations (P < 0.05) were observed for all items, indicating a strong relationship between hyposalivation and the symptoms reported in the questionnaire. For example, feeling dry mouth during meals, having difficulty swallowing, and feeling dry mouth at night or upon waking were significantly associated with hyposalivation. Similarly, the perception of low saliva levels, the need to chew gum or mints, and frequent thirst at night also showed significant associations with hyposalivation. In addition, conditions such as diabetes mellitus and hypertension were significantly related to hyposalivation, highlighting the interconnectedness of these health issues.

DISCUSSION

This study assessed the accuracy of a xerostomia questionnaire as a screening tool for detecting hyposalivation in the general population and explored its association with systemic conditions such as diabetes mellitus and hypertension.^[11] Among 200 individuals approached, 173 participants aged between 36 and 80 years (mean age: 56.32 years) met the inclusion criteria and were evaluated. Among the participants, 43.9% (n = 76) were females, while 56.1% (n = 97) were males.

The frequency of various xerostomia-related symptoms reported by participants underlines the clinical relevance of dry mouth as a prevalent concern.^[12] For instance, 6.9% of individuals reported always experiencing a dry mouth during meals, while 44.5% reported sometimes experiencing it, and 8.1% very often. Difficulty swallowing food was never experienced by 50.3%, but 4% always reported this difficulty. Approximately 9.8% of participants frequently perceived having a reduced amount of saliva, while 16.8% consistently reported experiencing dry mouth during the night or upon waking.

Despite 79.2% of participants never using chewing gum or mints to relieve dry mouth, and 82.1% not experiencing burning sensations on the tongue, a considerable proportion reported symptoms that align closely with hyposalivation.^[12] The statistical analysis revealed significant associations (P < 0.05) between hyposalivation confirmed by sialometry and multiple questionnaire items, including:

• Dry mouth during meals

• Difficulty in swallowing food

• Dry mouth at night or upon waking

• Perceived low saliva volume

• Frequent thirst at night.

These results confirm the effectiveness of the xerostomia questionnaire in identifying individuals with reduced salivary flow.

In addition, this study emphasized the relationship between hyposalivation and systemic conditions, with 32.4% of participants diagnosed with diabetes mellitus (27.2% on medication), and 30.1% affected by hypertension (25.4% on medication). These associations align with the established understanding that systemic diseases and long-term medication use can contribute to salivary gland hypofunction.^[6] Diuretics, antihypertensives, and hypoglycemics often have xerogenic side effects that compromise salivary secretion.^[13]

The statistical reliability of the questionnaire was supported by test-retest reliability measures using the Kappa statistic and the ICC, indicating good consistency in responses.^[10] Accuracy was further validated by comparing questionnaire results with sialometric findings through Spearman’s correlation and the Mann–Whitney test. These results reinforce the questionnaire’s utility as a non- invasive, cost-effective, and efficient screening tool for hyposalivation, especially valuable in primary healthcare and epidemiological settings where sialometry may not be feasible.^[12]

Moreover, nocturnal symptoms – particularly dry mouth upon waking – demonstrated strong associations with hyposalivation, suggesting that specific time-of-day questions could enhance the sensitivity of xerostomia screening. Although the study did not directly assess quality of life, the presence of symptoms such as difficulty in swallowing and frequent dryness can be expected to interfere with fundamental oral functions such as eating, speaking, and sleeping, thereby impacting overall well-being.^[14]

Despite the promising results, the study’s limitations include the use of convenience sampling, which may reduce generalizability, and the cross-sectional design, which does not allow for causal inferences or longitudinal tracking. Future research incorporating larger, more diverse samples and longitudinal follow-up will be essential to validate these findings and understand the long-term impact of hyposalivation.^[15]

In summary, the xerostomia questionnaire showed strong diagnostic potential as a screening instrument for hyposalivation. Its significant correlation with both clinical salivary flow measurements and underlying systemic conditions underscores the importance of integrating such tools into routine medical and dental assessments, particularly for patients with chronic illnesses.^[16] Early identification and appropriate intervention can prevent complications such as dental caries, oral infections, and poor oral hygiene, ultimately improving the patient’s quality of life.^[17]

CONCLUSION

The results indicate that the xerostomia questionnaire demonstrated greater accuracy as a screening tool for detecting hyposalivation. The significant associations between questionnaire responses and clinical indicators validate its potential as a valuable epidemiological tool for identifying suspected cases within populations. Given the strong relationship between hyposalivation and conditions such as diabetes mellitus and hypertension, integrating this screening tool into routine healthcare assessments could facilitate early detection and timely intervention. Individuals who yield positive results on the questionnaire should undergo additional diagnostic tests to confirm hyposalivation and receive appropriate clinical management. Further studies incorporating objective salivary flow measurements and longitudinal follow-ups are recommended to enhance diagnostic accuracy and assess long-term implications.