Singing & Dry Mouth: Things You Might Not Have Tried

M    y mouth gets incredibly dry when I sing. Are there any new things to try out there? A gel I tried once felt greasy in my mouth, so that was the end of that. And sprays I’ve tried only last about 10 minutes.”
  —  Anonymous email to CMT.

T he short duration of action you experienced with the sprays isn’t unusual. You need to remember that any extraneous material in the mouth tends to induce reflexive/habitual motions (of tongue, etc.) to remove it and clear it out. Products that would have a longer duration of action for regular people just sitting around and not talking or singing may not last so long for you during a vocal performance. Years ago, I used to take care of cancer patients, both immediately after radiation treatment and later in palliative care, so I do know something about the strengths and limitations of the ‘artificial saliva’ products that are available.

S ubjective dry mouth sensation is known as xerostomia. But when sialometry (performed by a physician immunologist or laryngologist) objectively demonstrates a saliva flow rate of under 0.2 mL/min (resting salivation rate) and under 0.7 mL/min (stimulated salivation rate), the fancy medical terms ‘hyposialia’, ‘sialopenia’, or ‘salivary hyposecretion’ are used—basically, saliva production less than 500 mL of saliva a day, against ‘normal’ losses of saliva to (mouth-open breathing-related) evaporation and ordinary swallowing of saliva: a deficient production compared to normal losses.

L ow saliva not what the question above was about, though. The question has mostly to do with increased evaporative losses associated with large minute-wise airflow for singing, against ‘normal’ saliva flow rates that are unable to keep up with the rate of loss. In some cases, the dry mouth may be exacerbated by stage fright or allergies or medications you might be taking or a health condition that causes the mouth to be dry. But, for many singers, it’s just the mismatch between the (modest-but-normal) rate of saliva production and the (singing-accelerated) rate of saliva loss.

T he artificial saliva material may not only migrate down the throat into the esophagus, but also (in small amounts) into the larynx. So with regard to singing, please be sure to try out whatever solution you are planning to use in advance—in rehearsals long before any public performance. You don’t want to do anything radically new or un-tested on-stage.

D ry mouth is treated with liquid or gel artificial saliva solutions that are designed so that they will be retained on the mucosal surfaces for a period of some tens of minutes at least, to provide lubrication. These solutions contain bioadhesive polymers (chains that range from a few thousand Daltons molecular weight up to about 100 KDa MW), often sodium carboxymethyl cellulose (CMC). Some newer ones have an oxygenated glycerine tri-ester (TGO) active ingredient. Most of these have a rather slippery/sticky ‘mouth-feel’, but are well worth a try.

• Biotene®
  
• Luborant®
  
• MouthKote® spray
  
• Oasis® spray
  
• Salivart®
  
• Saliveze®
  
• TGO® Spray
  
• Wyvern®
  
• Xialine®

G ellan gum and alginate also both form mucoadherent gels, albeit by a different mechanism (ionic strength of moisture at physiologic mucosal surface) than the others. There are a few over-the-counter products that have these as their active ingredients.

G el-based artificial saliva products have traditionally been more effective and last longer than ‘spray’ type artificial salivas. This has been extensively studied in palliative-care patients, especially terminal cancer. But there are some mucin-mimicking artificial saliva products that have been introduced just in the last two years that have performed well in clinical trials.

P oloxamers in 2% w/v to 5% w/v solutions are liquids at room temperature but gel at body temperature, once they are applied inside the mouth.

• Smart Hydrogel®
  
• Oasis® mouthwash

T he polyvinylpyrrolidone polymer within an anionic polymer solution (Oasis®) enables higher concentrations of mucoadhesive polymer than older products achieve. These PVP copolymer films stay ‘stuck’ to the mouth tissues for longer, while at the same time giving improved mouth-feel due to reduced slippery/sticky mouth-feel, compared to carboxymethylcellulose (CMC)-based artificial saliva products. I have tried Oasis® and think it works very well.

N ote that the Oasis® spray does not have poloxamer in it. You can use as required, up to a maximum of 60 sprays per day. Each application of the Oasis® mouthwash lasts about 2 hours; each application of the Oasis® spray keeps your mouth feeling moist for, at most, 60 min or so. The Oasis® mouthwash would probably work better for a singer performing longer concerts. (Supposedly, Mariah Carey uses MouthKote® spray…)

T alk to your retail pharmacist. Those with training in clinical pharmacy are well prepared to advise you on the pros and cons of the various products. Some pharmacies don’t stock these products, or have a small selection since it’s a low-volume type of item, used by relatively few patients. So you may have to look for mail-order options. The hyperlinks embedded in this CMT post will give you a few options you can check out.

O r talk to your dentist. With the exception of palliative medicine physicians, oncologist physicians, ENT physicians, immunologist physicians and some gerontologists, most physicians have little experience with dry mouth and are not expert in managing it. Dentists are, in general, very knowledgeable about OTC and prescription approaches to treating dry mouth. In the U.S., artificial saliva products are regulated by FDA CDRH as Class II 510(k) dental medical devices, not as drugs.

S ome products (like Salivese®, Glandosane®, BioXtra®, and Salivix®) are only licensed for dry mouth due to radiotherapy or Sjogren’s Syndrome and require a prescription. You don’t have to have one of those ‘on-label’ conditions to get a prescription for these. A physician or dentist could legally write a prescription for you (‘off-label’). But you would have to explain to them what your performing activity entails, and why you need a powerful artificial saliva—get them to understand why other things have not been adequately effective for you and why you therefore would like to try a prescription for one of these ‘heavier-duty’ artificial saliva products.

• Performing Arts Medicine Association (PAMA) [Medical Problems of Performing Artists journal]
  
• Bachelor H. Formulation strategies in mucosal-adhesive drug delivery. Controlled Release Society, 2005. [1MB pdf]
  
• Bots C, et al. The management of xerostomia in patients on haemodialysis: comparison of artificial saliva and chewing gum. Palliat Med. 2005; 19:202-7.
  
• Chen L-L, et al. Compositions and methods for mucosal delivery. U.S. Pat. 6,552,024. Issued 22-APR-2003.
  
• Corcoran R, Stovell A, Urquhart D, Chui T, Richardson M. Evaluation of a combined polymer system for use in relieving the symptoms of xerostomia. J Clin Dent. 2006; 17:34-8.
  
• Davies A, Finlay I, eds. Oral Care in Advanced Disease. Oxford Univ, 2005.
  
• Escobar-Chavez J, et al. Applications of thermo-reversible pluronic F-127 gels in pharmaceutical formulations. J Pharm Pharmaceut Sci 2006; 9:339-58.
  
• Furamoto E, Barker G, Carter-HAnson C, Barker B. Subjective and clinical evaluation of oral lubricants in xerostomic patients. Spec Care Dent 1998; 18: 113-18.
  
• Kleinegger C. Dental management of xerostomia--opportunity, expertise, obligation. J Calif Dent Assoc. 2007; 35:417-24.
  
• Shirodaria S, Kilbourn T, Richardson M. Subjective assessment of a new moisturizing mouth spray for the symptomatic relief of dry mouth. J Clin Dent. 2006; 17:45-51.
  
• Wong D, ed. Salivary Diagnostics. Wiley-Blackwell, 2008.