Stress-Related Oral Manifestations: Signs and Treatment

Psychological stress has been increasingly associated with multiple oral conditions affecting both soft and hard tissues of the oral cavity. Chronic stress may alter immune function, salivary flow, parafunctional habits, and inflammatory responses, contributing to the development or exacerbation of oral diseases.

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The most common stress-related oral manifestations include bruxism, temporomandibular disorders (TMD), recurrent aphthous ulcers, xerostomia, burning mouth syndrome, periodontal disease progression, and oral lichen planus.
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Understanding the pathophysiological mechanisms linking stress and oral health is essential for accurate diagnosis and multidisciplinary management. This article reviews the principal oral manifestations associated with stress, including their definitions and evidence-based treatment approaches.

✅ Introduction
Stress is defined as a physiological and psychological response to internal or external challenges that disrupt homeostasis. Chronic activation of the hypothalamic-pituitary-adrenal axis may increase cortisol levels, alter immune responses, and influence behavioral habits that negatively affect oral health.
In dentistry, psychological stress has been recognized as an important risk factor for several oral pathologies. Stress may contribute directly through neuroimmunological pathways or indirectly by promoting parafunctional habits, poor oral hygiene, unhealthy diet, smoking, and sleep disturbances.
The identification of stress-related oral manifestations is clinically relevant because many patients initially seek dental care before receiving psychological or medical evaluation.

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✅ Oral Manifestations of Stress

1. Bruxism
Definition
Bruxism is a repetitive jaw-muscle activity characterized by clenching or grinding of the teeth during sleep or wakefulness. Emotional stress and anxiety are considered major contributing factors.

Clinical Features
▪️ Tooth wear and enamel attrition
▪️ Tooth sensitivity
▪️ Muscle fatigue or pain
▪️ Headaches
▪️ Fractures of restorations
▪️ Hypertrophy of masticatory muscles

Treatment
▪️ Occlusal splints or night guards
▪️ Stress management therapy
▪️ Behavioral modification techniques
▪️ Sleep hygiene improvement
▪️ Physiotherapy for muscle relaxation
▪️ In severe cases, botulinum toxin injections may be considered

2. Temporomandibular Disorders (TMD)
Definition
Temporomandibular disorders are a group of musculoskeletal conditions affecting the temporomandibular joint, masticatory muscles, and associated structures. Stress may increase muscle tension and parafunctional activity.

Clinical Features
▪️ Jaw pain
▪️ Joint clicking or popping
▪️ Limited mouth opening
▪️ Facial pain
▪️ Ear discomfort
▪️ Muscle tenderness

Treatment
▪️ Conservative therapy with soft diet
▪️ Anti-inflammatory medications
▪️ Occlusal splints
▪️ Physical therapy
▪️ Cognitive behavioral therapy
▪️ Relaxation exercises

3. Recurrent Aphthous Ulcers
Definition
Recurrent aphthous stomatitis is a chronic inflammatory condition characterized by painful oral ulcers. Emotional stress is considered a common triggering factor.

Clinical Features
▪️ Painful round or oval ulcers
▪️ Erythematous halo surrounding lesions
▪️ Difficulty eating or speaking
▪️ Recurrent episodes

Treatment
▪️ Topical corticosteroids
▪️ Chlorhexidine mouth rinses
▪️ Pain control with topical anesthetics
▪️ Nutritional assessment
▪️ Stress reduction strategies

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4. Xerostomia
Definition
Xerostomia refers to the subjective sensation of dry mouth, often associated with reduced salivary flow. Stress and anxiety may alter autonomic nervous system activity, decreasing salivary secretion.

Clinical Features
▪️ Oral dryness
▪️ Difficulty swallowing
▪️ Burning sensation
▪️ Increased caries risk
▪️ Halitosis
▪️ Difficulty wearing dentures

Treatment
▪️ Adequate hydration
▪️ Saliva substitutes
▪️ Sugar-free chewing gum
▪️ Salivary stimulants such as pilocarpine (when indicated)
▪️ Fluoride therapy to prevent caries

5. Burning Mouth Syndrome
Definition
Burning mouth syndrome is characterized by chronic oral burning sensations without identifiable clinical lesions. Psychological stress and anxiety are strongly associated factors.

Clinical Features
▪️ Burning sensation on tongue or oral mucosa
▪️ Altered taste sensation
▪️ Oral dryness
▪️ Symptoms worsening throughout the day

Treatment
▪️ Psychological counseling
▪️ Cognitive behavioral therapy
▪️ Salivary substitutes
▪️ Topical clonazepam in selected cases
▪️ Stress control interventions

6. Periodontal Disease Exacerbation
Definition
Stress may influence periodontal disease progression by impairing immune responses and increasing inflammatory mediators.

Clinical Features
▪️ Gingival inflammation
▪️ Bleeding on probing
▪️ Periodontal pocket formation
▪️ Clinical attachment loss
▪️ Increased plaque accumulation secondary to poor oral hygiene habits

Treatment
▪️ Professional periodontal therapy
▪️ Scaling and root planing
▪️ Improved oral hygiene practices
▪️ Smoking cessation
▪️ Stress management programs
▪️ Regular periodontal maintenance

7. Oral Lichen Planus
Definition
Oral lichen planus is a chronic immune-mediated mucosal disorder that may worsen during periods of psychological stress.

Clinical Features
▪️ White reticular lesions
▪️ Erythematous or erosive areas
▪️ Burning sensation
▪️ Bilateral buccal mucosa involvement

Treatment
▪️ Topical corticosteroids
▪️ Symptom monitoring
▪️ Elimination of irritants
▪️ Psychological support
▪️ Periodic follow-up due to potential malignant transformation risk

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💬 Discussion
The relationship between stress and oral health is multifactorial and involves neuroendocrine, immunological, and behavioral mechanisms. Elevated cortisol levels may suppress immune function, alter inflammatory responses, and predispose patients to oral mucosal lesions and periodontal breakdown.
Additionally, stress-related behaviors such as bruxism, tobacco use, poor dietary habits, and neglect of oral hygiene further aggravate oral conditions. Several studies have demonstrated a significant association between psychological stress and the severity of temporomandibular disorders, recurrent aphthous ulcers, and periodontal disease progression.
Dental professionals should recognize the importance of psychosocial factors during patient assessment. A multidisciplinary approach involving dentists, psychologists, physicians, and physiotherapists may improve long-term outcomes in patients with chronic stress-related oral conditions.

🎯 Recommendations
▪️ Incorporate stress assessment into routine dental examinations.
▪️ Educate patients about the oral consequences of chronic stress.
▪️ Encourage adequate sleep and healthy lifestyle habits.
▪️ Promote regular dental check-ups for early diagnosis.
▪️ Consider referral for psychological or psychiatric evaluation when necessary.
▪️ Use minimally invasive and evidence-based management strategies.

✍️ Conclusion
Stress-related oral manifestations represent an important clinical challenge in modern dentistry. Conditions such as bruxism, xerostomia, aphthous ulcers, TMD, and periodontal disease may significantly compromise oral health and quality of life. Early recognition of stress-associated oral signs allows timely intervention and multidisciplinary management. Dentists play a critical role in identifying these manifestations and implementing preventive and therapeutic strategies supported by scientific evidence.

📚 References

✔ American Academy of Orofacial Pain. (2020). Orofacial pain: Guidelines for assessment, diagnosis, and management (6th ed.). Quintessence Publishing.
✔ Gomes, H. S., Corrêa-Faria, P., Malta, D. C., Bernardino, Í. M., Magalhães, I. B., Guerra, L. M., ... & Granville-Garcia, A. F. (2020). Association between psychological factors, bruxism, and temporomandibular disorders in adolescents: A systematic review. Journal of Oral Rehabilitation, 47(7), 909–921. https://doi.org/10.1111/joor.12979
✔ Goyal, S., Jajoo, S., Nagappa, G., & Rao, G. (2023). Psychological stress and oral health: A comprehensive review. Journal of International Society of Preventive & Community Dentistry, 13(2), 89–97. https://doi.org/10.4103/jispcd.jispcd_205_22
✔ Kaplan, J., & Coulter, C. (2022). The association between stress and temporomandibular disorders: A systematic review. Cranio, 40(1), 34–42. https://doi.org/10.1080/08869634.2020.1739952
✔ López-Jornet, P., Camacho-Alonso, F., & Lucero-Berdugo, M. (2015). Measuring the impact of stress in burning mouth syndrome. Journal of Oral Pathology & Medicine, 44(7), 569–574. https://doi.org/10.1111/jop.12277
✔ Peruzzo, D. C., Benatti, B. B., Ambrosano, G. M. B., Nogueira-Filho, G. R., Sallum, E. A., Casati, M. Z., & Nociti, F. H. (2007). A systematic review of stress and psychological factors as possible risk factors for periodontal disease. Journal of Periodontology, 78(8), 1491–1504. https://doi.org/10.1902/jop.2007.060371
✔ Scully, C. (2013). Oral and maxillofacial medicine: The basis of diagnosis and treatment (3rd ed.). Churchill Livingstone.
✔ Sharma, S., & Gupta, D. S. (2021). Stress and its role in oral diseases: A review. International Journal of Applied Dental Sciences, 7(2), 123–127.

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How to Treat Xerostomia? Causes and Symptoms

Xerostomia, commonly referred to as dry mouth, is the subjective sensation of oral dryness, frequently associated with reduced salivary flow (hyposalivation). This condition significantly affects oral health by increasing the risk of dental caries, periodontal disease, oral candidiasis, halitosis, and impaired mastication and speech.

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The etiology is multifactorial and includes medication use, systemic diseases, head and neck radiotherapy, and autoimmune disorders such as Sjögren syndrome. This article reviews the etiology, signs and symptoms, diagnosis, and treatment of xerostomia, based on current scientific evidence and clinical guidelines.

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✅ Introduction
Xerostomia treatment is a common challenge in dental and medical practice. Saliva plays a critical role in maintaining oral homeostasis by lubricating tissues, buffering acids, facilitating remineralization, and exerting antimicrobial effects. A reduction in salivary secretion compromises these protective mechanisms and predisposes patients to multiple oral complications.
The prevalence of xerostomia increases with age and polypharmacy, although it can occur at any stage of life depending on systemic and environmental factors.

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✅ Etiology of Xerostomia

Medication-Induced Xerostomia
More than 500 medications are associated with dry mouth, particularly:
▪️ Antidepressants
▪️ Antihypertensives
▪️ Antihistamines
▪️ Antipsychotics
▪️ Diuretics
▪️ Muscle relaxants

Systemic Diseases
Several conditions can impair salivary gland function, including:
▪️ Sjögren syndrome
▪️ Diabetes Mellitus
▪️ Parkinson's Disease
▪️ Alzheimer's Disease
▪️ Human Immunodeficiency Virus Infection

Cancer Therapy
Radiotherapy involving the head and neck can permanently damage salivary glands, especially when doses exceed 26 Gy.

Dehydration
Inadequate fluid intake, fever, vomiting, or diarrhea may temporarily reduce salivary flow.

Lifestyle Factors
▪️ Tobacco use
▪️ Alcohol consumption
▪️ Mouth breathing
▪️ High caffeine intake

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✅ Signs and Symptoms of Xerostomia
Common manifestations include:

▪️ Persistent dry mouth
▪️ Sticky or thick saliva
▪️ Difficulty chewing, swallowing, or speaking
▪️ Burning mouth sensation
▪️ Altered taste (dysgeusia)
▪️ Cracked lips and angular cheilitis
▪️ Halitosis
▪️ Increased dental caries
▪️ Recurrent oral candidiasis
▪️ Difficulty wearing removable dentures

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✅ Clinical Diagnosis
Diagnosis requires a combination of subjective and objective assessment.

Medical and Dental History
Evaluate medication use, systemic diseases, and previous radiotherapy.

Clinical Examination
Typical findings include:
▪️ Dry, erythematous mucosa
▪️ Absence of pooled saliva
▪️ Frothy or ropey saliva
▪️ Cervical caries and enamel demineralization

Sialometry
Unstimulated salivary flow rates below 0.1 mL/min are considered severely reduced.

Complementary Tests
When autoimmune disease is suspected, serologic testing and minor salivary gland biopsy may be indicated.

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✅ How to Treat Xerostomia

1. Identify and Correct the Underlying Cause
Whenever possible:
▪️ Review medications with the treating physician
▪️ Manage systemic diseases
▪️ Improve hydration status
▪️ Reduce alcohol and caffeine intake

2. Non-Pharmacological Treatment
Frequent Water Intake
Small sips of water throughout the day improve oral lubrication.
Sugar-Free Chewing Gum
Stimulates salivary secretion, especially products containing Xylitol.
Saliva Substitutes
Commercial artificial saliva products provide temporary relief.
Humidifiers
Nighttime use may reduce dryness related to mouth breathing.

3. Topical Preventive Measures
Sodium Fluoride Varnish
Essential for preventing root and coronal caries.
High-Fluoride Toothpaste
Prescription formulations containing 5,000 ppm fluoride may be indicated in high-risk adults.
Chlorhexidine
Used selectively to reduce cariogenic bacterial load.

4. Pharmacologic Sialogogues
Pilocarpine
Typically prescribed at 5 mg three to four times daily when residual salivary gland function is present.
Cevimeline
Particularly effective in patients with Sjögren syndrome.
Contraindications include uncontrolled asthma and narrow-angle glaucoma.

5. Management of Oral Complications
▪️ Antifungal therapy for candidiasis
▪️ Restorative treatment for caries
▪️ Lubricants for denture discomfort
▪️ Nutritional counseling

✅ Table: Evidence-Based Xerostomia Treatment

💬 Discussion
Xerostomia is both a symptom and a clinical condition with substantial implications for oral and systemic health. Although management often focuses on symptom relief, successful treatment depends on identifying the underlying cause and preserving residual salivary gland function. Preventive dentistry is essential, particularly in patients with medication-induced xerostomia and those receiving head and neck radiotherapy.
The introduction of pharmacologic sialogogues and high-concentration fluoride therapies has significantly improved clinical outcomes, but multidisciplinary care remains critical in complex cases.

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🎯 Recommendations
▪️ Assess xerostomia in all patients reporting oral dryness.
▪️ Perform salivary flow testing when available.
▪️ Apply fluoride varnish at regular intervals.
▪️ Encourage sugar-free xylitol products.
▪️ Refer patients with suspected Sjögren syndrome.
▪️ Use pharmacologic sialogogues when indicated.
▪️ Schedule frequent preventive dental visits.

✍️ Conclusion
Xerostomia treatment requires a comprehensive approach that combines etiologic diagnosis, symptom control, salivary stimulation, and prevention of oral complications. Early recognition and evidence-based management can significantly improve patient comfort, reduce disease burden, and preserve oral function and quality of life.

📚 References

✔ Villa, A., Connell, C. L., & Abati, S. (2015). Diagnosis and management of xerostomia and hyposalivation. Therapeutics and Clinical Risk Management, 11, 45–51. https://doi.org/10.2147/TCRM.S76282
✔ Turner, M. D., Hyland, K. A., & Ship, J. A. (2007). Drug-induced dry mouth: A critical review. Journal of the American Dental Association, 138(Suppl), 20S–24S. https://doi.org/10.14219/jada.archive.2007.0359
✔ Furness, S., Worthington, H. V., Bryan, G., Birchenough, S., & McMillan, R. (2011). Interventions for the management of dry mouth. Cochrane Database of Systematic Reviews, (12), CD008934. https://doi.org/10.1002/14651858.CD008934.pub2
✔ Plemons, J. M., Al-Hashimi, I., & Marek, C. L. (2014). Managing xerostomia and salivary gland hypofunction. Journal of the American Dental Association, 145(8), 867–873. https://doi.org/10.14219/jada.2014.44

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Why Does Diabetes Cause Dry Mouth? Understanding the Link Between Xerostomia and Blood Sugar Levels

Dry mouth, or xerostomia, is a common but often overlooked complication of diabetes mellitus. Affecting both type 1 and type 2 diabetes patients, this condition results from altered salivary gland function, often exacerbated by high blood glucose levels.

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✅ The Role of Saliva in Oral Health
Saliva is crucial for maintaining oral homeostasis. It lubricates the oral tissues, aids in digestion, neutralizes acids, and has antimicrobial properties that protect against infections and tooth decay. A decrease in saliva flow or a change in its composition can disrupt this balance, leading to:

° Increased risk of dental caries
° Oral infections, such as candidiasis
° Burning mouth sensation
° Difficulty speaking, chewing, and swallowing

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✅ How Diabetes Leads to Dry Mouth

1. Hyperglycemia and Fluid Loss
Persistent high blood glucose levels lead to osmotic diuresis—a process in which glucose is excreted in the urine along with large amounts of water. This results in systemic dehydration, which also affects the salivary glands. Dehydration reduces salivary output and increases oral dryness (Lopez-Pintor et al., 2016).

2. Neuropathy Affecting Salivary Glands
Diabetic neuropathy, a common long-term complication of poorly controlled diabetes, can damage the autonomic nerves responsible for salivary gland stimulation. This autonomic dysfunction leads to reduced salivary secretion and altered gland response (Darwazeh & Al-Dwairi, 2019).

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3. Microvascular Damage
Diabetes can impair blood flow due to damage in the small blood vessels (microangiopathy), including those that supply the salivary glands. Reduced perfusion limits the glands' ability to function properly, contributing to xerostomia (Ghezzi & Ship, 2003).

4. Medication Side Effects
Many people with diabetes are on multiple medications, including antihypertensives, antidepressants, and diuretics. These drugs are known to cause dry mouth as a side effect, compounding the issue (Scully, 2003).

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💬 Discussion
Xerostomia in diabetes is multifactorial and often worsens with poor glycemic control. The consequences are not limited to discomfort; dry mouth can significantly impair a patient's quality of life and lead to further systemic complications. For instance, diabetic patients with xerostomia are more likely to develop periodontal disease, which in turn can increase systemic inflammation and complicate blood sugar management.
Healthcare professionals—including endocrinologists, primary care physicians, and dentists—must work collaboratively to identify and manage xerostomia early. Glycemic control should be the cornerstone of treatment, alongside patient education, salivary substitutes, sugar-free lozenges, and regular dental evaluations.

💡 Conclusion
Dry mouth is a common and clinically significant symptom in patients with diabetes. It results primarily from dehydration, neuropathy, vascular damage, and medication use. Effective management requires a comprehensive, multidisciplinary approach centered on optimal blood sugar control and targeted oral care strategies. Awareness of this connection can improve both oral and overall health outcomes in diabetic populations.

📚 References

✔ Darwazeh, A. M. G., & Al-Dwairi, Z. N. (2019). The relationship between xerostomia and glycemic control in patients with type 2 diabetes mellitus. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 127(5), 409–416. https://doi.org/10.1016/j.oooo.2018.12.013

✔ Ghezzi, E. M., & Ship, J. A. (2003). Aging and secretory reserve capacity of major salivary glands. Journal of Dental Research, 82(10), 844–848. https://doi.org/10.1177/154405910308201106

✔ Lopez-Pintor, R. M., Casañas, E., González-Serrano, J., Serrano, J., & Hernández, G. (2016). Xerostomia, hyposalivation, and salivary flow in diabetes patients. Journal of Diabetes Research, 2016, 4372852. https://doi.org/10.1155/2016/4372852

✔ Scully, C. (2003). Drug effects on salivary glands: dry mouth. Oral Diseases, 9(4), 165–176. https://doi.org/10.1034/j.1601-0825.2003.03967.x

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Oral Manifestations of Systemic Diseases: Updated Clinical Review

Systemic diseases affect more than internal organs—they often present oral signs that can be essential for early diagnosis.

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✅ Systemic Diseases and Their Oral Manifestations

1. Diabetes Mellitus
➤ Definition: A chronic metabolic disorder characterized by persistent hyperglycemia.
➤ Oral manifestations:
° Xerostomia (dry mouth)
° Advanced periodontal disease
° Delayed wound healing
° Oral candidiasis
➤ Common signs and symptoms: Gingival bleeding, tooth mobility, halitosis, recurrent oral infections.

2. Iron Deficiency Anemia
➤ Definition: A lack of iron leading to decreased oxygen-carrying capacity of the blood.
➤ Oral manifestations:
° Pale oral mucosa
° Atrophic glossitis (smooth, sore tongue)
° Angular cheilitis
➤ Common signs and symptoms: Burning sensation in the mouth, altered taste, oral ulcers.

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3. HIV/AIDS
➤ Definition: Infection caused by the human immunodeficiency virus, impairing the immune system.
➤ Oral manifestations:
° Pseudomembranous candidiasis
° Kaposi's sarcoma
° Oral hairy leukoplakia
° Necrotizing gingivitis/periodontitis
➤ Common signs and symptoms: White lesions, persistent ulcers, oral pain, gingival bleeding.

4. Systemic Lupus Erythematosus (SLE)
➤ Definition: A multisystem autoimmune disease affecting connective tissues.
➤ Oral manifestations:
° Painless oral ulcers
° Erythematous or purpuric lesions
° Xerostomia (often secondary to Sjögren’s syndrome)
➤ Common signs and symptoms: Mild pain, difficulty chewing, mucosal and lingual changes.

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5. Chronic Kidney Disease (CKD)
➤ Definition: Progressive, irreversible loss of kidney function.
➤ Oral manifestations:
° Uremic breath odor
° Oral ulcerations
° Gingival bleeding
Enamel hypoplasia (especially in children)
➤ Common signs and symptoms: Metallic taste, oral pain, delayed tooth eruption in children.

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✅ Recommendations for Dental Practice

° Conduct thorough medical histories that screen for systemic illnesses.
° Treat oral signs as potential indicators of undiagnosed systemic disease.
° Work collaboratively with physicians for interdisciplinary care.
° Educate patients on the oral-systemic health connection.
° Schedule frequent cleanings and periodontal evaluations for at-risk patients.

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💡Conclusions
Oral signs of systemic diseases serve as critical indicators for early diagnosis and comprehensive treatment. Timely recognition of these signs can improve patient outcomes, reduce complications, and enhance quality of life. Dentists play a key role in identifying these manifestations and guiding patients to appropriate medical care.

📚 References

✔ Chávez, E. M., et al. (2022). Oral health considerations in patients with chronic kidney disease. Journal of Clinical Nephrology and Renal Care, 8(1), 110. https://doi.org/10.23937/2572-3286.1510110

✔ Kottoor, R., et al. (2020). Oral manifestations in patients with systemic lupus erythematosus. Lupus, 29(3), 274–281. https://doi.org/10.1177/0961203320903073

✔ López-López, J., et al. (2021). Oral manifestations of iron deficiency anemia: A clinical approach. Clinical Oral Investigations, 25(1), 123–130. https://doi.org/10.1007/s00784-020-03418-z

✔ López-Pintor, R. M., et al. (2020). Diabetes mellitus and oral health: A bidirectional relationship. Medicina Oral, Patología Oral y Cirugía Bucal, 25(4), e559–e566. https://doi.org/10.4317/medoral.24012

✔ Patton, L. L., et al. (2021). Oral manifestations of HIV infection and treatment: A clinical guide. Oral Diseases, 27(S1), 59–68. https://doi.org/10.1111/odi.13742

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How the symptoms of Dry Mouth can be combated ?

Dry mouth or xerostomia is the consequence of decreased salivary flow, and is basically the symptom of some disease, or side effect of certain types of medications.

Having a xerostomia creates a series of discomforts in the patient, such as: alteration of food taste, burning mouth, fissures or sores in the mouth, halitosis, difficulty speaking.

Enlaces Patrocinados


The patient with xerostomia must have good and correct oral hygiene and stimulate salivation. Pay attention to the recommendations of the bioXtra - DRY MOUTH RELIEF channel for patients suffering from xerostomia.

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Fuente: Youtube / bioXtra - DRY MOUTH RELIEF
Imagen: Pur Dental Center