178 Chapter 8 most dry than all other intra-oral regions except the anterior and posterior tongue and the pharynx (Table 1). This result shows that dryness of the posterior palate in combination with dryness of the anterior and posterior tongue seems to play a major role in choosing a dry-mouth intervention, much more than the total XI score. Other interesting findings were the significant associations between “using mouth gel’’ and the RODI score of the inside cheeks (Table 7). As seen in Table 1, the inside cheeks were considered as least dry region. However, when this region becomes more dry (Table 3, RODI score ≥ 3.5), patients tend to use a mouth gel that can be applied to this region to relieve its dryness. The frequently used dry-mouth interventions by Sjögren’s syndrome patients were “drinking water’’ and “moistening the lips’’. Drinking water was the most used (90.5%) intervention compared to all other dry-mouth interventions. As mentioned earlier by several systematic reviews, dry mouth products are not effective to relieve dry mouth [4, 6, 7]. Especially salivary substitutes, such as mouth gels and sprays, are not effective in reducing dry mouth symptoms or increasing the salivary flow [4, 6, 7]. This is in line with previous research that interviewed Sjögren’s syndrome patients in the Netherlands about their saliva substitutes usage [29]. These patients reported that they discontinued use of saliva substitutes after a short period of time due to lack of effectiveness [29]. Possibly for this reason, Sjögren’s syndrome patients prefer to drink water instead of using other dry-mouth interventions. Water is widely accessible at low costs. Drinking water can temporarily relieve the subjective sensation of dry mouth [30, 31]. However, the effectiveness and longevity of this strategy are limited [27], because the viscosity of water does not change with increasing shear [32]. In contrast, the viscosity of saliva decreases with increasing shear. In practice, this allows saliva to be easily spread on the oral surfaces as well as to be retained and not easily washed off oral surfaces [32]. For the reason, saliva has important lubricating properties in contrast to water. As a consequence, the effectivity of drinking water as a dry-mouth intervention is limited compared to saliva. Although the RODI scores for the upper and lower lip were lower than other regions such as the posterior palate, anterior and posterior tongue and the pharynx, patients frequently moisten their lips (Table 1). Maintaining moist lips appears to be important for patients and can be helped by the administration of simple water-based gels and ensuring humidification [33]. Another study concluded that scheduled use of ice water oral swabs and lip moisturizer with menthol may lessen thirst intensity and dry mouth [34].
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