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\def\RunningAuthor{Harshada Ragunathan et al.}
\firstPage{2381}
\articleType{Original Article}
\receivedDate{20 Sep 2020}
\acceptedDate{22 Oct 2020}
\revisedDate{10 Oct 2020}
\journalVolume{2020, 11 (SPL4)}
\journalDoi{ijrps.v11iSPL4.4481}
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\title{Aridity In Senior Citizens}
\author{Harshada~Ragunathan\textsuperscript{*},  
            Krithika~C,  
            Divya~G,  
            Nishanthi~L,  
            Priya~Ramani, 
            Gayathri~P~S~\\[5pt]{Department of Oral Medicine and Radiology, Thai moogambigai Dental college and Hospital, Dr MGR Educational and Research Institute, Chennai {\textendash} 600107, Tamil Nadu, India}}

\begin{abstract}
Hyposalivation contributes to several health problems. It can produce serious adverse effects on one's quality of life. The prevalence of dry mouth increases with age, and approximately 30\% of those aged 60 years and old are being affected. Ageing and medication are the salient causes of hyposalivation / Xerostomia. The study aims to analyse the salivary flow rate of senior citizens by a questionnaire method \& to confirm through clinical evaluation. The objective of the study is to show the importance of clinical evaluation of the oral cavity in estimating the salivary flow. The study was conducted among 40 senior citizens of age 60 \& above. The assessment of dry mouth was done by questioner method and by collecting unstimulated saliva. The collected data were subjected to statistical analysis, and chi-square test was performed. It showed that patients who believed that they were pretty fine also had hyposalivation clinically. 57.5\% of total participants had less salivary flow rate. Also, 67.5\% of participants showed oral manifestation of periodontitis with 7.5\% mirror stick appearance. 32.5\% of participants had dry-mouth out of which most of them were females and had no drug history. Even though there are many signs and symptoms for oral dryness, clinical evaluation always stands first in diagnosis. Patient under drug therapy and elderly patient's routine dental checkup can help them to know about their dental and general health status.  
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Drugs,\newline Dry mouth,\newline older people,\newline Hyposalivation,\newline Saliva,\newline Xerostomia
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Harshada~Ragunathan~\\ Phone:\ 9442532241~\\  Email:\ harshada.sragu@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
Saliva is the most valuable biochemical fluid which can be collected easily in a non-invasive method. Sialometry is the study of evaluation of salivary flow rate. Saliva can be collected in different forms like unstimulated whole saliva, stimulated whole saliva, glandular saliva (mainly parotid) - with or without stimulation, sub-mandibular/ sub-lingual saliva, palatine saliva \unskip~\citep{919258:20641941}.\textbf{\space }

The unstimulated salivary flow rate is approximately 0.3{\textendash}0.4 mL/min \unskip~\citep{919258:20641933}. A diagnosis of hyposalivation is made when the stimulated salivary flow rate is \ensuremath{\leq }0.5{\textendash}0.7 mL/min, and the unstimulated salivary flow rate is \ensuremath{\leq }0.1 mL/min \unskip~\citep{919258:20641940}. The xerostomia denotes the subjective feeling, the symptom of dry mouth, whereas hyposalivation denotes the sign, a decreased saliva flow rate \unskip~\citep{919258:20641939}. The term ``dry mouth'' has been used to describe both conditions \unskip~\citep{919258:20641935}. The prevalence of dry mouth increases with age, and approximately 30\% of those aged 60 years and old are being affected \unskip~\citep{919258:20641942}. Hyposalivation contribute to serious negative effects on the patient's quality of life by affecting dietary habits, nutritional status, speech, taste and tolerance to a dental prosthesis and increases the risk of oral infection \unskip~\citep{919258:20641931}.\textbf{\space }

The present study aims to analyse the salivary flow rate of senior citizens by a questioner method and to confirm through clinical evaluation. The objective of the study is to prove the importance of clinical evaluation and to educate the importance of general Oral Health in senior citizens. 
    
\section{Materials and Methods}
A cross-sectional study was conducted in the Out-Patient Department of Oral Medicine and Radiology. The study consists of 40 participants aged 60 and above. Participants who were willing to participate in the study were selected. Patient's who were under hormonal therapy, treatment for xerostomia, a habit of alcohol or tobacco, neurological disorders, history of radiotherapy or chemotherapy and Hysterectomy were excluded from the study. \textbf{\space }

After thoroughly explaining the study and obtaining the written consent, A set of 11 self-structured questions which was vetted by experts opinion were formed both in English, and regional language (Tamil) and were given to the participants. The demographic details inclusive of drug history was also obtained after which oral examination and collection of saliva proceeded.

For analysing the flow rate, participants were asked to rinse the mouth with water and open the mouth without swallowing saliva for 5 min. Accumulated saliva was collected by spitting method, and the flow rate was measured. The data obtained were subjected to statistical analysis.


\bgroup
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\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/504a4f58-3f90-4355-a22d-6bd95a1bd585-upicture1.png}{\includegraphics{images/504a4f58-3f90-4355-a22d-6bd95a1bd585-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Salivary Flow rate and Drug History }}
\label{f-fdfd7132c4bd}
\end{figure}
\egroup

    
\section{Results and Discussion}
Among the 40 participants who were selected based on the inclusion and exclusion criteria, 20 were males, and 20 were females. The age of the study participants ranged from 60 to 78 Years.  48\% of the total population had a history of systemic diseases. 


\begin{table*}[!htbp]
\caption{\boldmath {Response of participants.} }
\label{tw-bae9716d057c}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{LLLLLL}
\tbltoprule \rowcolor{kwdboxcolor}Sl. no &  Questions & Yes\% & No\% & Chi-square Value & P-Value\\
\tblmidrule 
1. &
  Does your mouth feel dry while eating? &
  7.5 &
  92.5 &
  3.243 &
  0.072\\
2. &
  Do you have difficulties in swallowing in any kind of food? &
  20 &
  80 &
  0.625 &
  0.429\\
3. &
  Do you need to sip liquids to aid in swallowing dry foods?  &
  37.5 &
  62.5 &
  0.960 &
  0.327\\
4. &
  Does the amount of saliva in your mouth seem to be reduced most of the time?  &
  25 &
  75 &
  0.533 &
  0.465\\
5. &
  Do you feel the dryness of mouth at night or on awakening? &
  42.5 &
  57.5 &
  0.921 &
  0.337\\
6. &
  Does your mouth feel dry during the daytime?  &
  5 &
  95 &
  2.105 &
  0.147\\
7. &
  Do you chew gum or use candy to relieve oral dryness?  &
  2.5 &
  97.5 &
  1.026 &
  0.311\\
8. &
  Do you usually wake up thirsty at night?  &
  45 &
  55 &
  0 &
  1\\
9. &
  Do you have problems with tasting food? &
  17.5 &
  82.5 &
  4.329 &
  0.037\\
10. &
  Do you have a burning sensation in the mouth? &
  2.5 &
  97.5 &
  1.026 &
  0.311\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Oral Manifestations of Senior Citizens.} }
\label{tw-b89a33d20dad}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.15990000000000002\linewidth-2\tabcolsep}p{\dimexpr.4711000000000001\linewidth-2\tabcolsep}p{\dimexpr.369\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No & Percentage of Participants & Oral Manifestation\\
\tblmidrule 
1 &
  67.5\%  &
  Periodontitis \\
2 &
  7.5\% &
  Mirror Stick Appearance \\
3 &
  10\% &
  Edentulous\\
4 &
  27.5\% &
  Gingivitis\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Correlation between drug intake and salivary flow rate.} }
\label{tw-1b8f6ca96a56}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{LLLLLLLLL}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{3}{p{\dimexpr(\mcWidth{1}+\mcWidth{2}+\mcWidth{3})}}{\multirow{2}{\linewidth}{}} & \multicolumn{5}{p{\dimexpr(\mcWidth{4}+\mcWidth{5}+\mcWidth{6}+\mcWidth{7}+\mcWidth{8})}}{Medications} & {\multirow{2}{*}{Total}}\\
\rowcolor{kwdboxcolor} &  &  & Antidiabetic drugs & Anti-hypertensives & Cardiac drugs & Combination \mbox{}\protect\newline Drugs & Nil & \\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{4}{\linewidth}{Dry \mbox{}\protect\newline mouth}} &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{\rAlignHack No}} &
  Count &
  0 &
  5 &
  1 &
  3 &
  8 &
  17\\
 &
   &
  \% of Total &
  0.0\% &
  12.5\% &
  2.5\% &
  7.5\% &
  20.0\% &
  42.5\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{\rAlignHack Yes}} &
  Count &
  2 &
  4 &
  1 &
  3 &
  13 &
  23\\
 &
   &
  \% of Total &
  5.0\% &
  10.0\% &
  2.5\% &
  7.5\% &
  32.5\% &
  57.5\%\\
\multicolumn{2}{p{\dimexpr(\mcWidth{1}+\mcWidth{2})}}{\multirow{2}{\linewidth}{Total}} &
  Count &
  2 &
  9 &
  2 &
  6 &
  21 &
  40\\
 &
   &
  \% of Total &
  5.0\% &
  22.5\% &
  5.0\% &
  15.0\% &
  52.5\% &
  100.0\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
During the clinical evaluation, it is seen that 57.5\% of the participants had less salivary flow rate. From Table~\ref{tw-bae9716d057c}, it is seen that 42.5\% of the population reported dryness of mouth at night or on awakening. Table~\ref{tw-b89a33d20dad} shows that 67.5\% of the participants had an oral manifestation of periodontitis, and 7.5\% showed mirror stick appearance. Also, from Table~\ref{tw-1b8f6ca96a56}  it is evident that dry mouth was seen in 32.5\% of participants with no drug history. The salivary flow rate of participants with and without drug history is shown in Figure~\ref{f-fdfd7132c4bd}.

32.5\% of participants with no drug history and 7.5\% of our participants who were in combination drugs suffered from dry mouth.

The X-axis denotes the participant number, and Y-axis denotes the salivary flow rate (ml/5min). Black colour represents the patient with no drug history, Maroon for patients who are under antidiabetic drug, Lavender for cardiovascular drugs, Orange for antihypertensive drug, green for the combination of antidiabetic and hypertensive drug, blue for the combination of antihypertensive, antidiabetic and cardiovascular drugs and beige for the combination of antidiabetic and cardiovascular drugs.

Saliva plays a vital role in the human body. A decrease in the level of saliva leads to dental caries, periodontal problems, ill-fitting denture, mucositis, dysphagia, oral infection and many other problems. Patients with severe xerostomia are 2.3 to 4.9 times more likely to have a negative experience \& negative impact on the quality of life \unskip~\citep{919258:20641932}. Prevalence of dry mouth was considerably high among elderly patients. 

It is always believed that females have increased risk of dry mouth than males which was spotted in our study, where 70\% of the females had dry mouth. This was in accordance to \unskip~\citep{919258:20641938,919258:20641945} and \unskip~\citep{919258:20641934}  who showed high prevalences of subjective perception of dry mouth in women in their studies.

Medications may act on CNS and neuroglandular junction that are involved in the initiation of salivary secretion \unskip~\citep{919258:20641947}. Sven Niklander et al. in his study showed that 82\% patients with xerostomia had a systemic disease and 70.5\% were in combination drugs at the time of the study \unskip~\citep{919258:20641945}. In our study, 7.5\% of our participants who were in combination drugs had dry-mouth.

There are many studies which have proved that dryness of mouth is more common among patients who are under medication. The frequency of xerostomia is mostly related to the dose and number of medications \unskip~\citep{919258:20641929}. But in our study patients who were not under any medication also had decreased salivary flow rate.

Womanhood experience an upsurge in oral symptoms that may result from reduced estrogen level, calcium, vitamin deficiency, and several psychological issues throughout menopausal years. The most substantial oral symptom found in the menopausal women is oral dryness \unskip~\citep{919258:20641930}.

The patient usually complains of dry mouth or burning mouth in case of any decrease of saliva flow. But according to our study, not all self -reported information is right and as asking patients if his or her mouth is dry are insufficient measures for clinicians to use to determine if the patient has hyposalivation \unskip~\citep{919258:20641948}.

Prevention programs and treatment of hyposalivation \& xerostomia can improve the patient's quality of life \unskip~\citep{919258:20641946}. Treatment includes replacing oral fluids with water; avoiding caffeinated, sweet or acidic drinks; stimulating the salivary glands with sugarless gums \& candies; using systemic sialogogic agents such as pilocarpine \& cevimeline \unskip~\citep{919258:20641936}.

The limitations of this study are that it was carried in a smaller sample size for a shorter duration of time and the probability of patient's honesty is questionable. 
    
\section{Conclusions}
It is imperative from our study that, dryness of mouth is strongly seen in elderly females and in people who are under a combination of drugs. Obtaining routine unstimulated salivary flow rates in addition to self-reported information may increase early detection of oral dryness, which would assist in implementing early interventions. 

\textbf{Funding Support }

The authors declare that they have no funding support for this study.

\textbf{Conflict Of Interest }

The authors declare that they have no conflict of interest for this study.
    

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