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 Table of Contents  
Year : 2019  |  Volume : 31  |  Issue : 3  |  Page : 234-238

Comparative evaluation of unstimulated whole salivary flow rate and oral symptoms in healthy premenopausal and postmenopausal women - An observational study

1 Department of Oral Medicine and Radiology, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India
2 Department of Oral Medicine and Radiology, AMC Dental College, Ahmedabad, Gujarat, India

Date of Submission11-May-2019
Date of Acceptance10-Aug-2019
Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Pritesh Ruparelia
47, Jai Ambika Society, Isanpur Road, Maninagar, Ahmedabad, 380 008, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_104_19

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Introduction: Menopausal women undergo many physiological changes, most of which are due to decreased estrogen production. Little is understood about the relationship between menopause and oral health. Aim and Objectives: To evaluate the association of menopausal status on subjective reports of oral discomfort and on the objective measurement of unstimulated whole salivary flow rate in healthy women. Materials and Methods: A total of 200 women, including 100 postmenopausal and 100 premenopausal women, were divided into two groups based upon their menstrual status. Group I consisted of 100 postmenopausal women in the age group of 44–76 years. Group II consisted of 100 premenopausal women in the age group of 31--45 years. Settings and Design: A standardized visual analog scale questionnaire was administered to obtain subjective sensation of oral discomfort. Unstimulated whole saliva was collected for 5 min by spitting method and the flow rate of saliva was measured per minute. Statistical analysis used: Chi-square, Student's t test, and analysis of variance (ANOVA) were applied. Results: The prevalence and intensity of the subjective symptoms of oral discomfort was significantly higher in postmenopausal women as compared to the premenopausal women (P < 0.001). The unstimulated whole salivary flow rates in pre- and postmenopausal women were 0.4 ± 0.13 and 0.2 ± 0.11 ml/min, respectively (P < 0.001). A significant association between symptoms of oral discomfort [burning sensation (P = 0.001), taste disorders (P < 0.001), dry mouth (P < 0.001)], and unstimulated salivary flow rate was seen in postmenopausal women. Conclusion: The results from this cross-sectional study of healthy females not being treated for any systemic disease, and not taking medications for any medical disorders indicated that the objective measurements of unstimulated whole salivary flow rate are influenced by menopause. In addition, subjective symptoms of oral discomfort are also associated with menopause.

Keywords: Oral discomfort, premenopausal women, postmenopausal women, unstimulated whole salivary flow rate

How to cite this article:
Gill N, Ruparelia P, Verma O, Ruparelia K. Comparative evaluation of unstimulated whole salivary flow rate and oral symptoms in healthy premenopausal and postmenopausal women - An observational study. J Indian Acad Oral Med Radiol 2019;31:234-8

How to cite this URL:
Gill N, Ruparelia P, Verma O, Ruparelia K. Comparative evaluation of unstimulated whole salivary flow rate and oral symptoms in healthy premenopausal and postmenopausal women - An observational study. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2022 Dec 9];31:234-8. Available from: http://www.jiaomr.in/text.asp?2019/31/3/234/268266

   Introduction Top

The older age groups are the most rapidly growing segments of the general population. In order to provide more effective medical, dental, and social services to the elderly, it is necessary to better understand the oral consequences of physiological and pathological ageing.[1]

Menopause is the permanent cessation of menstruation and ovarian function, characterized by the lack of estrogen production.[2] While the systemic aspects of menopause are well documented, there is still a need to spread awareness about oral discomfort, as a part of menopausal complaints.[3]

As saliva is essential for maintenance of oral health, it is important to assess the extent to which menopause affects saliva.[2] In the current scenario, a controversy still exists on the association of menopause with salivary flow rate and the association of oral symptoms with salivary flow rate.[4]

The present study was therefore conducted with the purpose of evaluating the association between menopausal status and subjective reports of oral discomfort and on objective measurement of unstimulated whole salivary flow rate in healthy women.

   Materials and Methods Top

A total of 960 women, who reported to the OPD of College of Dental Sciences and Research Centre, Ahmedabad, were screened for this study, over a period of 3 months.

  1. Ethics: Study design was approved by the institutional ethical committee and informed consent was taken from all the participants.
  2. Study design: After following the inclusion and the exclusion criteria, a total of 200 women participated in the study.

Selection and description of participants

The women were divided into two groups based upon their menstrual status. Group I consisted of 100 postmenopausal women in the age group of 44–76 years. Group II consisted of 100 premenopausal women in the age group of 31--45 years.

The inclusion criteria for premenopausal women were the last spontaneous menstrual bleed less than 6 months ago and that for postmenopausal women was last spontaneous menstrual bleed more than 12 months ago.

Exclusion criteria included subjects with systemic diseases, oral candidiasis, smokers, obese patients (body mass index > 24), mouth breathers, history of radiotherapy, alcoholism, and those under medication.[5],[6] Patients with complete dentures and those having fewer than 20 teeth were also excluded from the study.[7] The selected participants were asked to answer a questionnaire with a list of oral discomfort symptoms.

Technical information

The questionnaire was designed to produce “yes” or “no” answers to a series of questions about three oral symptoms -subjective dry mouth (subjective oral dryness), burning mouth (burning sensation at the oral mucosa), and perceived taste disturbance (distorted taste or loss of taste).[8] This questionnaire was in accordance with the one designed by Toidaet al.[9]

The questions –

  • Does your mouth usually feel dry?
  • Does your mouth usually have a burning sensation?
  • Does your mouth usually have a taste disturbance (distorted taste or loss of taste), were used as indicators of subjective dry mouth, burning mouth, and taste disturbance respectively.

If the participants answered “yes”, the intensity of the complaints was assessed by using visual analog scales for dry mouth (VAS-DM), for burning mouth (VAS-BM) and for taste disturbance (VAS-TD), each of which was graded from 0 to 100, where 0 is no subjective symptoms and 100 is the worst symptom imaginable; thus, intensity of subjective symptoms was presented as an integer from 0 to 100. The subjects were asked to mark their responses to each item by placing a vertical line on the 100 mm horizontal scale.[9]

On the contrary, for the participants who answered “No,” a VAS value of 0 was given.[9]

The questionnaire was filled by individuals prior to the measurement of unstimulated salivary flow rate to avoid the possibility that the VAS scores may be affected by knowing the unstimulated salivary flow rate value.[9],[10]

The whole unstimulated salivary flow rate (USFR) was determined by spitting method, described by Navazesh and Kumar.[11],[12] Saliva was collected in a graduated test tube graded in 0.2 ml increments upto 10 ml, fitted in a funnel. Saliva was collected in a quiet environment and the samples were collected from all subjects between 9 a.m. and 11 a.m. to minimize any circadian rhythm effects.[13]

With low forced spitting, the unstimulated saliva was then collected per minute for 5 minutes in the graduated test tube fitted with funnel.[14]

The flow rate was then calculated in milliliters per minute. In both the groups, a value less than 0.1 ml/min was considered 'very low', between 0.1-0.2 ml/min was considered 'low' and more than 0.2 ml/min was considered 'normal'. Women in both groups were further divided into 'normal', 'low' and 'very low' USFR subgroups.

(C) STATISTICS: The statistical analysis in the present observational study was done using SPSS (Statistical Package for Social Sciences) Version 15.0 statistical Analysis Software. The values were represented in Number (%) and Mean ± SD. Chi-square, Student's t test, Analysis of variance (ANOVA) were applied. A criterion of P <.05 was accepted for significance in all statistical tests.

   Results Top

Prevalence and intensity of subjective oral dryness, subjective burning sensation and altered taste sensation in both the groups is summarized in [Table 1] and [Table 2] respectively.
Table 1: Prevalence of oral discomfort, subjective oral dryness, burning sensation, and taste disorders in both groups

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Table 2: Comparison of intensity of oral discomfort symptoms in two groups

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Mean and Level [Quantity per minute]-wise comparison of whole USFR between both the groups is outlined in [Table 3] and [Table 4], respectively.
Table 3: Comparison of whole unstimulated salivary flow rate (USFR) in two groups

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Table 4: Level.wise comparison of whole unstimulated salivary flow rate (USFR) in two groups

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Association between whole unstimulated salivary flow rate and intensity of oral symptoms in both the groups is elaborated in [Table 5].
Table 5: Association between whole unstimulated salivary flow rate and intensity of oral symptoms in Post and premenopausal women

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   Discussion Top

Menopause with its absence of specific hormonal stimuli may be a cause or a predisposing factor for oral discomfort.[15] In addition, researchers have proposed that menopause may also affect salivary gland function, since salivary glands contain sex hormone receptors.[16]

Many studies have examined salivary flow rates in the context of aging, but the results are conflicting. Some authors have reported significantly lower salivary flow with age,[8],[17],[18],[19],[20] and others have not.[21],[22],[23] Affoo et al. suggested that no age-related decreases in unstimulated or stimulated parotid saliva occur.[19]

However, variations in study designs, saliva collection methods, and selection of outcome measures may account for the lack of consistent findings among studies.

Therefore, to minimize age related alterations in the USFR, premenopausal women above 30 years were included in this study.

Flink et al., reported that the loss of teeth was responsible for the decrease in bite force and subsequent decrease in salivary flow rate.[18] Thus, subjects with less than 20 teeth were also not included in this study.

In the present study, the prevalence of oral dryness was 44%, burning sensation was 4%, and taste disorder was 5.1% in postmenopausal women. These results were in accordance with most of the previous studies, thereby revalidating their findings [2],[4],[24],[25],[26],[27] However, the intensity of subjective oral dryness and the severity of taste disturbance in the postmenopausal women was significantly higher as compared to premenopausal women. Oral dryness could be due to the hormonal alterations taking place at menopause, causing vasomotor, neurological, and psychological changes,[2] whereas the reasons for dysgeusia in menopause appear to be multifactorial, involving the interaction of biological and psychological systems.[24]

In our study, the severity of burning sensation was lower as compared to previous studies. A possible explanation for this could be that our study was performed on healthy menopausal women, while most of the previous studies assessed the intensity of burning sensation on diagnosed cases of burning mouth syndrome which included both elderly women as well as men.[28],[29]

Although in most of the studies, stimulated saliva was determined, in this study, estimation of the USFR was preferred. Saliva collected without any masticatory or gustatory stimulus is a more reliable indicator of reduced salivary flow rate.[2]

The mean whole USFR in postmenopausal women in this study was higher as compared to the USFR reported by Mojabi et al. in their study.[4] The reason for decreased values in their study, despite an equal sample size as ours, could be the fact that they used a 5 cc syringe to aspirate the saliva expectorated in a disposable cup, per minute by the subject. It is possible that not all of the saliva was aspirated completely from the cup, which might account for the decreased USFR in their study.[4]

Our results were in accordance with the previous reported literature, thereby reaffirming that decreased salivary flow rate does exist following menopause.[2],[30],[31]

The present study demonstrated a significant association between the prevalence of oral discomfort and USFR in postmenopausal women. Our results were in contrast to the study conducted by Agha-Hosseini et al. who reported no significant differences in the salivary flow rates in menopausal women with and without oral dryness. However, they assessed the stimulated salivary flow rates as opposed to the USFR determination in our study.[32]

The results of our study clearly indicate that menopausal women experience significant oral discomfort compared to premenopausal women.

   Conclusion Top

The results of the present study point out the high prevalence of oral discomfort in menopausal women which may have debilitating repercussions on the health-related quality of life of these women.

This study has also addressed an important clinical issue regarding the relationship between oral sensorial complaints and salivary flow rate in menopausal women. Every effort should be made by the clinician to improve the quality of life in these women by administering artificial saliva, maintaining good oral hygiene, and enhancing natural salivary secretion with secretagogues, if required. More studies on the effect of Hormone replacement therapy (HRT) on amelioration of oral discomfort symptoms and salivary flow rates must also be explored.


The study received approval from the ethical committee of the institution where the study was conducted (College of Dental Sciences and Research Centre, Bopal, Ahmedabad), on 3/5/2018 and informed consent was taken from all the patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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