XEROSTOMIA AS A CLINICAL MANIFESTATION OF DRUG INDUCTION ON PATIENTS WITH

HISTORY OF HYPERTENSION AND DIABETES MELLITUS TYPE 2

Lindari Latifah Nurul Rahmah1, Haris Budi Widodo2

1Dental Profession Study Program, Jenderal Soedirman University, Purwokerto, Central Java
2Oral Biology Laboratory, Faculty of Dentistry, Jenderal Soedirman University, Purwokerto, Central Java
Correspondence Address: Jenderal Soedirman University Faculty of Dentistry, Purwokerto, Central Java,
Indonesia, 53112 Email: lindarilatifah@ymail.com

ABSTRACT
Xerostomia is a condition of a dry mouth due to reduced or absent of salivary flow. Xerostomia is not a
disease, but it is a symptom of various conditions such as the treatment received, side effects of the radiation
on the head and neck, or side effects of various drugs. A 68-year-old female patient had a dry mouth
complaint and the corner of her mouth sometimes felt cracked. Medical history shows that patients suffering
from hypertension and Diabetes Mellitus type-2. Patients routinely take amlodipine as antihypertensive
drugs with a dose of 5mg per day, 2mg of glimepiride insulin per day, and 500mg of metformin antidiabetic
medication per day. On intraoral examination shows the condition of fissure tongue, dry at corner of the lip and
using full denture. The therapy required is palliative, and use other formulas of stimulus.
Keyword: xerostomia, hipertensi, diabetes mellitus

Xerostomia comes from the Greek language
meaning dry (xeros) and mouth (stoma).
Xerostomia is described as a decrease in the rate
of salivary stimulation secretion. Xerostomia
which is indicated as a decrease in saliva
production is generally caused by several factors,
among others, radiotherapy, old age, systemic
disease and drug induction.1,2
Systemic disease closely related to the
continuous consumption of drugs
hypertension. The progression of blood pressure
generally increases with age. Age-related
hypertension is seen more at systolic pressure
than diastolic. Systolic pressure increases in the
eighth or ninth decade, whereas diastolic blood
pressure remains constant or increases after age
40.1 Prevalence of hypertension increases with
age in all age groups and races. The prevalence
of age in white men aged 18-29 years is 3.3%.
This prevalence increased by 13.2% in the 30-39
year age group; 22% at the age of 40-49 years;
37.5% in the 50-59 years age group; And 51% in
the 60-74 age group. 3.4
Antihypertensive drugs consist of several
is type, but commonly used types is calcium
channel blockers (CCB) such as amlodipine and
nifedipine. Consumption of antihypertensive
drugs in the long run can cause some side
effects. One of the main complaints in the oral

1
cavity in the patients who routinely consume CASE REPORT
A 68-year-old female patient came to RSGM
antihypertensive drugs is xerostomia.6,7
Unsoed with dry mouth complaints and frequent
In the systemic condition, Diabetes melitus
dry sores at the corners of her mouth. Patients
(DM) is also closely related to the occurrence of
also complained about the difficulty in using
xerostomia in the oral cavity. DM is a group of
Complete Dentures so routinely use additional
metabolic diseases characterized by high levels
adhesives. Medical history shows that the patient
of glucose in the blood (hyperglycemia) due to
suffers from hypertension and diabetes mellitus.
insulin secretion abnormalities, abnormalities of
Patients routinely take antihypertensive drugs in
insulin work, or a combination of both. Diabetes
the form of amlodipine with dosage of 5 mg per
Mellitus has two main types of insulin dependent
day, insulin drugs glimepiride 2 mg per day, and
DM Type 1 (Insulin Dependent Diabetes Mellitus
antidiabetic drugs metformin 500 mg per day.
/ IDDM) and type 2 DM non-insulin dependent
Blood pressure 142/76 mmHG, Pulse Rate 80x /
(Non Insulin Dependent Diabetes Mellitus /
min, fasting glucose 134 mg/dl, 2 hours glucose
NIDDM). Patients with DM Type 1 are
tolerance test 169 mg/dl. Intraoral examination
approximately 5-10% of all diabetics with 90-95%
showed the patient using full denture. On the
of diabetic patients is suffered from Type 2
patient's tongue, fissure tongue is formed. The
diabetes. Epidemiological studies shows the
corner of the mouth is slightly dry.
tendency of increasing in incidence and
prevalence rates of Type 2 DM in different parts
of the world.11
In controlled diabetes mellitus, patients also
have oral xerostomia manifestations. If
xerostomia is left for a long time it will cause
various complications in the oral cavity, such as
diabetic gingivitis, periodontitis, candidiasis,
angular cheilitis, dental caries and dry mouth Figure 1. Fissure tounge in midline of the dorsal surface.
syndrome, so that patients with DM who
experience xerostomia will suffering both
physically and psychologically.5 This makes the
treatment of xerostomia due to complications of
DM and hypertension is very important.

2

Figure 2. Using full denture
Figure 3. The corner of the mouth is slightly dry
Figure 4. (A) Saliva without stimulus (B) Saliva with
stimulus
3
Supporting examination were performed to
measure the patient's salivary rate. Measurement
of salivary rate aims to determine the presence or
absence of salivary production disorders in
patients due to systemic conditions experienced
by patients. Saliva rate measured is unstimulated
saliva and stimulated saliva. Based on the
measurements, the unstimulated patient saliva
rate was 0.1 ml / min while the stimulated salivary
rate was 0.7 ml / min.
DISCUSSION
Xerostomia or hyposalivation is a condition
about speed decreasing on stimulation of salivary
secretion. This condition is not a disease, but
symptoms or indication from pathophysiology
process and caused by many factors such as
nervous system disorders, medication, salivary
gland disorders, radiation therapy especially on
neck and head. Somebody convicted suffering
xerostomia if his saliva production less than half
normal daily production. Normally, stimulated
salivary flow rate about 1,5 ml 2 ml/minute,
meanwhile the unstimulated salivary flow rate
range from 0,3 0,4 ml/minute. Diagnosis from
hyposalivation can be enforced by quantifying
patients salivary flow rate. When quantifying
pure salivary, patient is not allowed to eat and
drink within 60 minutes before salivary flow rate
mensuration has been done. Salivary flow which
measured is unstimulated salivary flow rate
(USFR) and stimulated salivary flow rate (SSFR).
Unstimulated salivary flow rate 0,1 g/min and
stimulated salivary flow rate 0,7 g/min is a
xerostomia indication.2
Individuals with xerostomia often complain
about eating, talking, swallowing, and using
denture problems. Dry food usually hard to be
chewed and ingested. Denture usage also
experiences the problem with denture retention,
lesions, sticky tounge at palatum. Several
etiologies from xerostomia are derived from
systemic and continue drugs usage for long
period.8
A. Hypertensi
Antihypertensive drugs used
extensively and should continuously used to
maintain health, but side effects of
antihypertensive drugs must be dealed with
each patient. oral cavity complaint is one of
side effect often found in hypertension
patient. Antihypertensive drug category
which often used by hypertension patient is
CCB. Its really effective to reduce blood
pressure, works directly on blood vessels to
cause relaxation, and often become first-line
therapy. CCB is also really effective to
reduce blood pressure for elder population,
obesity, tanned skin, and people with
diabetes. great to prevent the stroke
occurrence but no better diuretic, ACE-
Inhibitor and Angiotensin Receptor Blockers
(ARB) to prevent heart failure. CCB divided
into two categories : 1) Dihydropyridine
calcium channel blockers i.e: amlodipine,
felodipine, nifedipine, and nicardipine; 2)
4
non-dihydropyridine calcium channel
blocker i.e: diltiazem and verapamil.10
CCB works on autonomic nervous,
there is parasympathetic nerves that later
have neurohumoral displacement pattern
like sympathetic nerves which cause work-
intervention from salivary glands to flow
salivary itself, so the salivary becomes
eased. Synergistic effect from two or three
antihypertensive drugs combination usage
can raise xerostomia possibility. Study
worked by Nonzee, et al found that 50%
patients who use antihypertensive drugs
experience xerostomia.9
B. Diabetes Mellitus (DM)
Diabetics are associated with the
occurrence of xerostomia due to changes in
atrophy of the salivary glands in accordance
with the age increase which will decrease
salivary production and change its
composition. As the ages grow, aging takes
place. There is a change and deterioration
of salivary gland function, where the
parenchyma gland disappears and will be
replaced by connective tissue and fat. This
leads to a reduction in the amount of salivary
flow.11
The association of DM with xerostomia
shows that patients with DM who have
xerostomia have blood glucose levels above
100 mg / dl when fasting and above 140 mg
/ dl for blood glucose 2 hours after eating. It
was concluded that the higher blood sugar
levels of patients with DM, the higher the
possibility to occur xerostomia.11
Research conducted Kartimah explain
the cause of xerostomia in DM. According to
her, xerostomia in DM occurs due to
congenital neuropathy disorder or due to
damage to the cervical nerve VII (facial
naevus) and cranial nerve IX
(glosopharyngeal nerve), which is the nerve
that controls the parotid glands (69%) of
salivary sources.16
The mechanism of pathogenesis
between DM and changes in salivary gland
function is not apparent, but long-term
hyperglycemia conditions result in
dehydration as a consequence of polyuria
which is a major cause of xerostomia and
salivary gland hypofunction in DM patients.
Dehydration alone can not cause changes
in salivary gland function. The lymphocytic
infiltrate seen in labial salivary gland tissue
indicates that salivary gland tissue is the
target of an autoimmune process similar to
that of pancreatic cells.13,14
Continuous degradation of salivary
gland tissue will cause 10-25% of
occurrence of hypofunction and impaired
salivary composition. Type I and II DM can
cause asymptomatic bilateral enlargement
of the parotid gland and sometimes the
submandibular gland commonly called
diabetic sialosis.15
There are two things that are often a
degenerative complication of DM that is
5
autonomic neuropathy and mikroangiopati
that cause structural disturbances in the
salivary gland tissue and then there
hipofungsi on this gland and influenced
autonomic inervation and microcirculation in
glandular tissue. Patients with diabetic
neuropathy reported an increase and
decreased salivary flow rate. Xerostomia
and salivary gland hypophilia are often
reported to be associated with DM disease
where poor metabolic control occurs.14
C. Case Management
Handling cases of xerostomia due to the
induction of antihypertensive drugs and
systemic Diabetes Mellitus is a general
approach of palliative therapy that serves to
reduce symptoms and prevent oral
complications.14 Several formulations are
also recommended such as the use of
mouthwash, aerosol, low-sugar gum and
dentifrices can also trigger Salivary
secretions.15
CONCLUSION
In patients with diabetes mellitus and
hypertension who routinely consume drugs have
manifestations of oral cavity xerostomia bias
performed management with palliative therapy,
artificial saliva, as well as some stimulus
products such as mouthwash, low-sugar gum
and dentifrices.
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