Zeroing in on xerostomia
Xerostomia, or dry mouth, is a common concern in the dental field, with millions of people affected by it (Fox PC, 2008; Guggenheimer J, Moore PA, 2003; Streebny LM, Valdini A, 1987; Streebny LM, Schwartz SS, 1997). The condition may be temporary or permanent (Wilkins EM, 2009).
The main causes of xerostomia are medication use, head and neck cancer treatments, autoimmune diseases or systemic diseases, and salivary gland removal (Wilkins EM, 2009; American Society of Aging, 2008).
Over-the-counter and prescription drugs are often the culprits behind xerostomia (Fox PC, 2008; Wilkins EM, 2009). As the number of medications taken increases, so does the risk of xerostomia. The 2000 Report of the Surgeon General indicates that more than 400 drugs can cause xerostomia (Streebny LM, Schwartz SS, 1997; American Society of Aging, 2008; Hupp WS, 2008; Oral Health in America: A Report of the Surgeon General, 2000).
Antihistamines, diuretics and antidepressants are the three most commonly used types of medications that cause xerostomia (American Society of Aging, 2008).
Head and neck cancer treatments
Cancer patients receiving head and neck radiation or chemotherapy often experience dry mouth. Treatments may decrease or stop the saliva flow due to inflammation or the saliva glands’ inability to function (American Society of Aging, 2008). During treatment, major and minor salivary glands are injured or damaged by ionising radiation, which causes atrophy of the secretory components and produces temporary or permanent xerostomia (Guggenheimer J, Moore PA, 2003).
Various systemic diseases and conditions impact dryness in the oral cavity. Patients with xerostomia symptoms may have an underlying disease that is not being treated, such as: Sjögren’s syndrome; diabetes mellitus; Parkinson’s disease; hypo- and hyper-thyroidism; adrenal cortex disease; renal disease; alcoholic cirrhosis; cystic fibrosis; Bell’s palsy; sarcoidosis; amyloidosis; graft-versus-host disease; depression; HIV/AIDS; nutritional deficiencies; and eating disorders and malnutrition (anorexia, bulimia, dehydration) (Fox PC, 2008; Guggenheimer J, Moore PA, 2003; Wilkins EM, 2009; American Society of Aging, 2008; Delaleu N et al, 2008).
People who breath through their mouths may experience dry conditions that lead to the inflammation of gingival tissues – changing the size, shape, surface textures, and consistency (Wilkins EM, 2009). Saliva reduction is also influenced by stress, anxiety, eating a soft food diet (Wilkins EM, 2003; Alty CT, 2003) or drinking caffeinated products (Fox PC, 2008). Recreational drugs, especially methamphetamines and ecstasy (amphetamines, barbiturates, and benzodiazepines), also cause xerostomia (Wilkins EM, 2009; Darby ML, Walsh MM, 2003).
Patients who have had their salivary glands removed will definitely experience xerostomia (Wilkins EM, 2009). Saliva flow may also be stopped or decreased through mechanical blockage or salivary stones (sialolithiasis). The submandibular gland is the most common location (Hupp WS, 2008).
Determining if a patient has xerostomia is important because changes in the flow of saliva can have far reaching oral health implications. Here follows is a series of suggested questions to ask patients whom you suspect may be experiencing dry mouth (Fox PC, 2008; Bartels CL, 2008):
1. How long have you been experiencing the pain/condition and how often?
2. What prescription or over-the-counter medications or supplements/vitamins are you taking?
3. Do you frequently moisten your mouth or lips?
4. How much water are you consuming on a daily basis?
5. At mealtimes, do you have difficulty swallowing or chewing dry foods?
6. Do you have any chronic diseases or conditions, e.g. Sjögren’s syndrome, diabetes, hypertension, depression, anxiety?
7. When was your last complete physical examination? Dental examination?
8. How often do you brush?
9. Do you have toothaches, pain, or sores on your lips or inside your mouth?
10. Do you wear dentures or partials? How often do you clean them?
11. Have you had head or neck cancer therapy?
12. Have your salivary glands been removed?
The following can also help dental hygienists to identify the presence of xerostomia: acquiring a health history; oral examination; determining saliva flow rate; scintigraph/scintiscan; and biopsy of minor salivary glands (Fox PC, 2008; Sjögren’s Syndrome Foundation, 2008).
In reviewing the health history, the duration, frequency and severity of dry mouth need to be ascertained. Other notable sites to question include the eyes, nose, throat, skin and vagina. A thorough health history includes a list of the medications and over-the-counter drugs being used by the patient (Sjögren’s Syndrome Foundation, 2008).
During a health history, the salivary glands should be palpated to observe tenderness, firmness, swelling and the amount of saliva dispersed or not dispersed. Observe if the colour is red or if the oral mucosa has a dry appearance (Sjögren’s Syndrome Foundation, 2008).
A saliva flow test should be administered to determine the amount of saliva flow during a given time period. Two saliva tests available are Saliva Check (GC) and CRT buffer caries risk test (Ivoclar Vivadent), which take approximately 10 to 15 minutes and provide immediate results.
Saliva results include stimulated and unstimulated flow levels, consistency, quantity, pH and buffering capacity. Another type of saliva test, the CRT bacteria test (Ivoclar Vivadent), requires a 48-hour incubation period from the time of the saliva sample. Check stimulated and unstimulated saliva flow because results may indicate a saliva gland pathology (Sjögren’s Syndrome Foundation, 2008; Nieves A, Fitzgerel-Blue W, 2008).
The scintigraph is an in-hospital, invasive procedure used to determine saliva flow through a procedure using small amounts of injectable radioactive material taken up by blood from salivary glands and secreted into the mouth (Sjögren’s Syndrome Foundation, 2008). Scintigraphs are excellent for observing salivary function and changes in salivary dysfunction, e.g. salivary stones (sialoliths), duct blockage, constriction or damage, tumors and cysts (Fox PC, 2008).
The most invasive procedure for diagnosing saliva gland malfunction is the biopsy of minor salivary glands located in the lower lip (Fox PC, 2008; Sjögren’s Syndrome Foundation, 2008). Specifically, the labial minor gland is the best for examining characteristic changes of Sjögren’s syndrome (Fox PC, 2008; Bartels CL, 2008; Sjögren’s Syndrome Foundation, 2008).
Treatment will vary according to the cause. When caused by medications, the medication regimen should be altered (Sjögren’s Syndrome Foundation, 2008). Conferring with the patient’s physician should be considered when xerostomia is due to systemic problems.
When dry mouth occurs, extra steps are necessary for proper oral care. Patient care should include: brushing gently a minimum of twice daily; flossing; fluoridated toothpaste (or amorphous calcium phosphate, NovaMin or Recaldent for demineralisation); rinsing/brushing with fluoride gels; use of fluoride custom trays; avoiding sticky sugary foods or brushing immediately afterwards; regular appointments with an oral healthcare professional (Darby ML, Walsh MM, 2003; National Institute of Dental and Craniofacial Research, 2008; MedicineNet.com, 2008); and breathing through the nose (MedicineNet.com, 2008).
Artificial saliva will reduce xerostomia for short periods of time. Saliva stimulants are available via prescription (prilocaine and cevimeline). These provide relief for several hours. However, they do come with side effects and they may cause tooth decay (Sjögren’s Syndrome Foundation, 2008).
Also available are fluoride gels and liquids. Commercial products are available in mouthrinses, sprays, solutions, gels and lozenges (Bartels CL, 2008). Chlorhexidine and antifungal agents may reduce related infections (Fox PC, 2008; Hupp WS, 2008; Darby ML, Walsh MM, 2003). Chewing gum helps to stimulate the saliva, causing an increased saliva flow. Other product materials to stimulate saliva flow are available, such as mints, sweets and liquids (Nieves A, Fitzgerel-Blue W, 2008).
A salivary function assessment should be part of providing intra-oral examinations. Patients need not suffer with dry mouth with no relief. Products have become more accessible and user-friendly, while oral lubricants and saliva substitutes are becoming more available.
Patients also need to be advised on how xerostomia relates to their overall health, and what they need to do to control it and prevent it from causing other problems. Dental professionals can definitely make a difference in patients’ overall and oral health in regard to dry mouth.
Alty CT (2003) The wonders of spit. RDH 23(6): 1-3
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National Institute of Dental and Craniofacial Research (2008) Dry mouth. Available at: www.nidcr.nih.gov/ OralHealth/Topics/DryMouth. Accessed 22 October 2008
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Surgeon General (2003) Oral health in America: a report of the Surgeon General. Rockville, Md: US Department of Health & Human Services, National Institute of Dental and Craniofacial Research, National Institute of Health; 32, 51, 107
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Reproduced with permission from Dimensions of Dental Hygiene. November 2008; 6(11): 40-42