Badooie F, Imani E, Hosseini-Teshnizi S, et al. Comparison of the effect of ginger and aloe vera mouthwashes on xerostomia in patients with type 2 diabetes: a clinical trial, triple-blind. Med Oral Patol Oral Cir Bucal. 2021;26(4):e408-e413.
Determining and comparing the benefit of ginger, aloe vera, and normal saline mouthwashes for the relief of xerostomia in patients with type 2 diabetes
A triple-blinded study
Investigators enrolled 105 participants and then divided them into 3 groups of 35. All participants were diagnosed with type 2 diabetes and xerostomia based on the Fox et al scale and the visual analog scale (VAS), and they consented to participate in the study.
The normal-saline group consisted of 17 males and 18 females, aged 58.13 ± 14.75 years. The aloe vera group consisted of 11 males and 24 females, aged 53.37 ± 11.57 years. The ginger group consisted of 15 males and 20 females, aged 54.14 ± 9.35 years.
Exclusion criteria consisted of the presence of oral ulcers or infection, having excessive physical activity, the use of mouthwash or saliva substitutes, physical or mental limitations, or migratory considerations.
Participants received 20 cc of either 25% ginger, 50% aloe vera, or normal saline (control). Participants were to hold the solution in their mouths for 1 minute and then expectorate, 3 times a day for 14 days. Investigators assessed the presence of xerostomia prior to and after the study using a 10-question survey developed by Fox et al, where the participant answers yes or no, and a linear VAS from 0 to 100.
Study Parameters Assessed
The study assessed improvement in the subjective feeling of xerostomia, reflected in a lower total score from the Fox questionnaire and in a linear decrease in the VAS.
Primary Outcome Measure
Difference in the pre-intervention and post-intervention total score from the Fox questionnaire, validated with changes in the VAS, with a decrease indicating improvement in the subjective feeling of xerostomia.
All 3 groups achieved statistically significant improvement in xerostomia (P<0.001). The ginger group had the highest reduction in total score (VAS2 – VAS1 = –6.12 ± 2.004 cm); followed by the aloe vera group (–4.08 ± 2.09 cm) and the saline group (–2.48 ± 2.09 cm).
The authors point out that xerostomia, a subjective feeling of a dry mouth, occurs in up to 80% of diabetics, but they failed to call attention to many other causes of xerostomia, including the use of many medications, supplement usage, psychological factors, Sjogren’s syndrome, rheumatoid arthritis, lupus erythematosus, scleroderma, hypothyroidism, radiation of the head and neck area, and salivary glandular disease.1,2 With such prevalence, along with an apparent increase in autoimmune diseases of all types, it would behoove all practitioners to be aware of the difficulties experienced by patients suffering from subjective symptoms of dry mouth. In fact, a paper by Deepak Daryani rates xerostomia as the fourth most distressing symptom known.3
The authors elucidate the possible sequelae from xerostomia including infections of the oral cavity, accumulating bacteria that can become systemic, fungal infections, respiratory pathology, and cardiovascular implications. Possible complications associated with xerostomia are difficulty in speaking, swallowing, or tasting food, as well as the inability to retain dental prosthesis. These are quite serious implications, and all diminish the quality of life.
While several objective means have been implemented to determine the salivary flow rate, these are more pertinent to hyposalivation, which is a decrease in salivary flow from a normal unstimulated flow rate of 0.3 to 0.4 mL/min to 0.1 mL/min or less.1 These measurements are quite involved and time-consuming and are best suited for investigative purposes. A more pragmatic approach may be the utilization of a questionnaire developed by Sreebny and Valdini in which the patient is asked 1 question: “Does your mouth usually feel dry?” This 1 question showed a sensitivity of 93%, specificity of 68%, a positive predictive value of 54%, and a negative predictive value of 98%. The addition of 3 related conditions (difficulty of speech, trying to keep the mouth moist, and getting out of bed to drink) increased the specificity to 91% and the positive predictive value to 75%.2
The addition of clinical signs certainly aids in the diagnosis of xerostomia. Osailan et al presented and validated some of these clinical signs, which include: a mouth mirror or tongue depressor sticking to the buccal mucosa or the tongue, frothy saliva, lack of saliva pooling in the floor of the mouth, loss of papillae on the dorsum of the tongue, altered gingival architecture, glassy appearance to oral mucosa, lobulated or fissured tongue, more than 2 teeth with cervical caries, and mucosal debris on the palate.4
Possible complications associated with xerostomia are difficulty in speaking, swallowing, or tasting food, as well as the inability to retain dental prosthesis.
The use of aloe vera and ginger for the treatment of xerostomia has been previously studied, and their effectiveness is well-documented. What was interesting in this study was the choice of normal saline for use in the control group. This, of course, seems counterintuitive in that the osmotic action of the sodium chloride should pull fluid out of the mucosa, only to be expectorated, resulting in a worsening of the condition. The results of the study, however, indicate a reduction in the total Fox and VAS scores, ie, an improvement. So, what gives? An answer may be found in the study conducted by Deepak Daryani and Gopakmar R in which they found that the saliva from xerostomia patients contained more than 3 times the amount of sodium and more than 2 times the amount of chloride as what is found in control patients’ saliva.3 Thus, water would be pulled from the normal saline into the mucosal tissue, moisturizing it. It is unknown whether the authors were aware of this finding and, if so, a different control could have been considered.
It should come as no surprise that frequent sips of water are the number 1 home remedy for patients suffering from xerostomia.5 Water, however, is subject to the same limitation that applies to salivary substitutes and other liquids used to relieve the xerostomia symptoms, and that is the time of efficacy, which usually is less than 15 minutes. This limitation explains why most patients prefer gels over liquids or sprays.6 Lozenges, such as lemon drops, are considered salivary stimulators but are only effective if the salivary glands are functioning normally, which unfortunately in many patients they are not. This is also true of pharmacologic stimulants such as pilocarpine, which is accompanied by possible disagreeable side effects.
The literature is robust with various natural products proven to be effective in relieving the symptoms of xerostomia including but not limited to: milk, olive oil, canola oil, linseed oil, sesame oil, yam mucilage, marshmallow root, honey, propolis, chamomile, Calendula officinalis, peppermint, essential oils, and of course aloe vera and ginger.7,8
Aloe vera and ginger are excellent treatment options. They are familiar, easy to obtain, and exhibit known safety profiles. They both are antibacterial, antiviral, antifungal, antioxidant, and immunomodulating.9,10 They both exhibit antimicrobial action against S mutans and Lactobacillus ssp,10,11 which are the primary pathogens that cause dental caries.12 They are effective against Candida albicans10,13 and have been found to be as effective against periodontal disease as chlorhexidine.14,15 Ginger is known to stimulate salivary secretion when taken systemically as well as topically.10 Aloe vera contains a sticky polysaccharide, acemannan, which increases its effectiveness and aids in the retention of dental appliances.9
While the authors do not provide any information about the method of blinding the participants to the solution they received, one has to wonder how they disguised the various tastes of aloe vera, ginger, and normal saline. The authors did not elucidate what effect using an essential oil such as peppermint or spearmint would have had. However, utilizing ginger and aloe vera proved to be effective, and we should place them in our arsenal of treatment options for xerostomia patients.
Interestingly, ginger with rosemary in a gel form or ginger, natural honey, and bitter chocolate have been demonstrated to remineralize enamel as effectively as fluoride.16,17