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Introduction

Xerostomia is the subjective feeling of oral dryness which may be due to hyposalivation. Saliva plays a vital role in the protection mechanism of buccal cavity. Xerostomia is generally present as a symptom rather than a disease and is characterized by dryness of mouth, bad breath, burning of oral cavity, altered taste and difficulty in swallowing, etc [1]. As many aetiologies have been described for dry mouth, it may be due to side effect of various medications, can be associated with Sjogren syndrome and even secondary to head and neck radiation therapy. [2] the prevalence of xerostomia ranges from 5.5% to 46% in the population [3]. In 2020, during COVID pandemic, xerostomia was found as a symptom in many patients. A study was conducted in 1017 COVID- 19 patients and the prevalence of xerostomia was found to be 43% among them [4]. It probably was because of the inflammation followed by atrophy of salivary glands by sars-cov-2[5]. Management of xerostomia includes regular intake of water and fluids and local topical measures, such as saliva substitutes [6]. Based on the similarities of symptoms, xerostomia may be correlated to Talushosha mentioned in Talugata rogas in ayurveda under Mukharogas. Talusosha is characterized as excessive dryness, cracks and dysponea [7] and even may be secondary to fever and excessive exertion [8]. The management of Talushosha mentioned by Acharya Sushruta is Snehana, Swedana and other Vata shamana chikitsa [9].

Patient information

A 48-year-old male patient reported in OPD on July 2021 with complaints of dryness of mouth, sore throat, burning sensation in mouth for past 1 month. Even after brushing the teeth twice daily, he was having bad breath. He was previously detected as positive for COVID-19 about 45 days prior to the OPD visit. Since then, he also complained of decreased sensation of taste. On detailed history, symptoms started during COVID-19 positive phase, but, continued even after recovery. He already took allopathic medication for the same but no satisfactory   relief   in   symptoms was noticed with that. Medical history showed that no other systemic illness was there.

Clinical findings

Physical examination: The patient was afebrile. Pulse rate was 76/min, respiratory rate was 18/min and blood pressure was114/80mmhg. No history of diabetes mellitus, hypertension.

History of COVID -19 1.5 months back.

Local examination

On inspection / Darshan Pariksha: After taking the history from the patient local examination of the oral cavity was done by inspection [10]. The picture of the oral cavity was taken before the initiation of  the treatment and features of the disease was shown [Figure 1]

The general findings on inspection before starting of the treatment mentioned in the table given below [Table 1]

On palpation / Sparsha Pariksha

1. Salivary gland on palpation found to be non-tender.

2. On touching, finger adhere to the oral mucosa.

Timeline

The patient experienced the symptoms like dryness of mouth, burning sensation, bad breath, lack of taste and sore throat. After visiting the OPD, he underwent the treatment for 30 days. The procedure was started from 12th July 2021 and continued till 13th august 2021. He attended three follow-ups, two in between the treatment on 8th and 16th day and the last one was on 31st day, i.e., after completion of the treatment.

Diagnostic assessment

Patient was assessed using subjective characteristics (lakshanas) of Talushosha mentioned in ayurvedic classics and subjective symptoms of xerostomia [11]. [Table 2]

Challacombe scale was used for assessing dry mouth clinically [12].  Total score is 10 that indicates severe dryness. [Table 3]

Intervention

For the Mukha Rogas one of the effective procedure Gandusha is mentioned in the classics that. Yastimadhi Siddha Gandusha was given for a period of one month three times per day of the treatment of TaluShosha. [Table 4]                                       

Follow up and outcomes

After starting the treatment follow up was done 8th, 16th and 31st day. The reduction in the dryness of parts of oral cavity was assessed and mentioned in percentage on the follow up days.  [Table 5]

The changes in the buccal cavity on 8th day and 31st was shown the pictures. [Figure 2], [Figure 3]

On palpation

On 8th ,16th and 31st day of treatment

1.Salivary gland on palpation found to be non-tender.

2.On touching, finger not adhere to the oral mucosa.

 The assessment of lakshanas like dryness of mouth, burning sensation, sore throat , halitosis and hypogusia was done by questionnaire method (prashna pariksha) and relief in the symptoms told by the patient were reported in percentage form. [Table 6]

Discussion

The etiological factors that precipitated this patient’s condition may be infection of sars-corona virus-2 that caused inflammation and atrophy of salivary glands and led to hyposalivation. According to Acharya Sushruta, vitiation of vata and pitta causes dryness of mouth and is responsible for other symptoms which were present in this patient. Also, COVID-19 can be considered as a vishama-jwara. Acharyas have mentioned that Talushosha can be present secondary to jwara. Based on this, this case of xerostomia may be corelated to Talu shosha.

Probable mode of action of yastimadhu siddha dugdha

Talushosha occurs due to vitiation of vata as well as pitta. The combined effect of vata and pitta leads to symptoms like dryness of mouth, burning sensation, sore throat. If not treated, it will further cause complications like hypogeusia, halitosis and even dyspnoea. Yastimadhu siddha dugdha gandusha used for the management of talushosha [13]. Yastimadhu and Dugdha being vata pitta shamaka [14], [15] directly cause samprapti vighatana of the roga and overcome the shosha of mukha and deernta. Both dravyas having madhura rasa, madhura vipaka and sheeta virya, so, they reduce burning sensation in mouth. Madhura rasa enlivens the function of mouth throat and tongue[16]. It also nourishes the sense organs and thus helps to regain the sense of taste[17]. Snigdha guna of yastimadhu and ksheera will provide soothing effect, moisten the oral cavity and help in proper hydration of the buccal mucosa[18] [19]. sheeta virya of both the dravyas will exhilarate and moisten the oral cavity[20]. It also reduces the pitta[21]. [Table 7]

Probable mode of action of Glycyrrhiza glabra

Glycyrrhiza glabra has natural sweetness and it may stimulate the gustatory salivary reflex that will further help in reducing the dryness of mouth[22]. it is also having antimicrobial and anti-inflammatory action[23]. g. Glabra credits to anti-oxidant activity, as it contains flavonoids and isoflavone that will reduce the chance of further cell damage[24]. Polysaccharide in Glycyrrhiza glabra raises the immune response by stimulating macrophages and also shows immune-stimulating activity[25] . Furthermore, it prevents virus multiplication and disrupts the virus particle; thereby, having potential immunomodulatory activity[26].All these properties will act on cell level and help in reduction of symptoms of Talu Shosha and elimination of the disease.

Probable mode of action of milk

Many of the chemical and physical properties of milk appears same to that of saliva. Hence it may act as a good saliva substitute. Moreover, it provides lubrication and moisture to the dry oral mucosa. It also buffers oral acids. Hence it reduces oral health problems related with hyposalivation [27]. Thus, the combined effect of Yastimadhu Siddha Dugdha and Gandusha shows effective result in the management of xerostomia in post COVID-19 patient.

Probable action of gandusha procedue

Gandusha is a process of holding any oil, decoction, Ghrita or any liquid in mouth to its full capacity without any movement for specific time [28]. Mechanical pressure is exerted by medicated liquid filled in oral cavity which stimulate mechanoreceptors and chemoreceptors in oral cavity. It will transfer signal to brain where the salivary nuclei are situated. This will cause the activation of parasympathetic nervous system; as a result of which facial and glossopharyngeal nerves come into action and stimulate the salivary gland to secrete more saliva [29]. The warm medicated liquid used for Gandusha will increase the vascular permeability and the active constituents of medicated liquid irritate the oral mucosa. Thus, medicated liquid get rapidly absorbed and helps to cure the disease [30]. Gandusha with medicated liquid will also help in dislodging the metabolic waste food debris and infective microorganism present in oral cavity. Thus, helps in improving the oral hygiene and maintain the pH of oral cavity [31].

Conclusion

Xerostomia has a variety of possible causes. It may even be secondary to various diseases. During the COVID-19 pandemic, there were many patients having the complaints of dryness of mouth and loss of sensation of taste. Yastimadhu Siddha Dugdha Gandusha proved to be highly effective in reducing the subjective symptoms of xerostomia in this post COVID-19 patient without any side effects. Also, he was advised to take more of fluid-based diet during and even post treatment. Since the effect is monitored in one patient only with focusing on the subjective symptoms of xerostomia hence for the forth coming researcher may pursue further study in this aspect.