Saliva: The wind beneath our wings

Extra credit for recognizing the bird in the cover photo as a Swallow.

Part 2

In the first part of this post, I discussed the love/hate relationship I have with mucus. This sentiment of course stems from my experience in dysphagia management. But for swallowing to occur, the body NEEDS secretions. Has to have it. Without it would be like white water rafting without the water. 

The miracle that is saliva

Mucus and its close cousin, saliva are responsible for coating the aerodigestive structures. To be clear, saliva contains mucus so they are more than cousins, actually, more like Siamese twins (Nosek, 2016). Without the proper viscosity of these secretions, these structures become dry, and like a machine without oil, the function starts to break down. 

Saliva is a wonderful thing. Its main purpose is to lubricate the mouth and throat to create an easy river for the bolus. It also contains enzymes responsible for beginning the digestion process and breaking down food particles in the mouth before they even get to the pharynx (Fejerskov, 2007). But wait, there’s more. Saliva contains a chemical that allows the taste buds to work effectively (Casais et al., 2011). That delicious lunch you’re plowing through while reading this? Saliva is what makes it taste so good (that and the bacon).

Take a look

One of the first things I do when I evaluate a patient is to assess their oral cavity. How do the lips, tongue, and gums look? Dry, cracked, or red? Or Moist, smooth, and pink? Saliva, or lack thereof (hyposalivation), will determine how the oropharyngeal structures are moving and how a bolus will move through them. Food and liquids are meant to partially dissolve in saliva. Eating with hyposalivation is like trying to swallow a tumbleweed. Ever try the saltine cracker challenge? 

The functional impact of hyposalivation can make it look like your patient has significant issues with oropharyngeal strength and range of motion by causing poor bolus transit and increased residue (Logemann et al., 2001). So that patient that you’ve got doing 10,000 effortful swallows, might just need a glass of water (or 8). 

What can we do?

So maybe you’ve been misdiagnosing your patient as having weakness when it’s actually dry mucosa. It’s ok, don’t be too hard on yourself. There’s still a lot we can do for hyposalivation. The first thing is to make sure they have it. The most widely used diagnostic tool is the OHAT. The best part, it’s super quick and easy. 

First, understand

The treatment of course depends on the cause; medications being the most common. If your patients are on many, chances are one of them causes hyposalivation. Common culprits include anticoagulants, antidepressants, antihypertensives, antiretrovirals, hypoglycemics, levothyroxine, multivitamins and supplements, non-steroidal anti-inflammatory drugs, and steroid inhalers (Villa et al., 2014). Reading this list alone is giving me dry mouth. Other common causes are radiation therapy and Sjogren’s syndrome (Thomson, 2005). Lastly, depression, anxiety, and malnutrition can also play a part (Bergdhal and Bergdhal, 2000). 

Then fix

First piece of advice? Talk to your IDT (novel, right?). Are there certain medications that can be eliminated? Reduced? Substituted? There are medications that improve salivation as well, but these have side effects of their own (Plus, treating meds with meds is like treating a headache by banging your head against the counter). Next, see if we can get them more hydrated (hint: the thickened liquids you recommended aren’t helping). Other simple solutions include chewing gum, lozenges, mouth sprays, and saliva substitutes (Villa et al., 2014).

Cheers

Saliva is important. It’s the wind beneath the wings of the bolus. Diagnosing dry mouth is quick and easy and there are plenty of simple ways to manage it. So before you get all excited with the newest dysphagia gadget, see if hyposalivation is the issue. Your patient will thank you for it. Cheers to that. 

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References:

Bergdahl M, Bergdahl J. Low unstimulated salivary flow and subjective oral dryness: association with medication, anxiety, depression, and stress. J Dent Res. 2000;79(9):1652–1658

Logemann, J. A., Smith, C. H., Pauloski, B. R., Rademaker, A. W., Lazarus, C. L., Colangelo, L. A., Mittal, B., MacCracken, E., Gaziano, J., Stachowiak, L., & Newman, L. A. (2001). Effects of xerostomia on perception and performance of swallow function. Head & Neck, 23(4), 317–321. https://doi.org/10.1002/hed.1037

Fejerskov, O.; Kidd, E. (2007). Dental Caries: The Disease and Its Clinical Management (2nd ed.). Wiley-Blackwell. ISBN 978-1-4051-3889-5.

Manuel Ramos-Casals; Haralampos M. Moutsopoulos; John H. Stone. Sjogren's syndrome: Diagnosis and Therapeutics. Springer, 2011. p. 522.

Nosek, Thomas M. "Section 6/6ch4/s6ch4_6". Essentials of Human Physiology. Archived from the original on 2016-01-17.

Thomson WM. Issues in the epidemiological investigation of dry mouth. Gerodontology. 2005;22(2):65–76. 

Villa, A., Connell, C., & Abati, S. (2014). Diagnosis and management of xerostomia and hyposalivation. Therapeutics and Clinical Risk Management, 45. https://doi.org/10.2147/tcrm.s76282