2011-04-27

Xerostomia

XEROSTOMIA
Maria Gawrioek

Xerostomia (dry mouth) subjective complaint of dry mouth that may result from a decrease in the production of saliva.

Salivary Gland Dysfunction and Xerostomia

Xerostomia

Clinical Appearance:

Oral mucosa appears dry, pale, or atrophic. Tongue may be devoid of papillae with fissured and inflamed appearance. New and recurrent dental caries. Difficulty with chewing, swallowing, and tasting may occur. Fungal infections are common.

Xerostomia

Saliva
Dry mouth (xerostomia) occurs when there is a change in the quality or a decrease in the quantity of saliva.

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Importance of Saliva in oral health:

Importance of Saliva in oral health:

It keeps the teeth healthy by providing a lubricant, calcium, and a buffer. It also helps to maintain the health of oral tissues (mucosa), and throat. It also plays a role in the control of bacteria in the mouth. It helps to cleanse the mouth of food and debris.

It provides minerals such as calcium, fluoride, and phosphorus. It helps in swallowing and digesting food. Lack of saliva will make the mouth more prone to disease and infection. Lead to a burning feeling.

Pathophysiology

Secretion of saliva
Normal secretion of non stimulated saliva is 0.30.4 ml/min. Secretion less than 0.1 ml/min = xerostomia Normal secretion of stimulated saliva is 1-2 ml/min Secretion less than 0.2-0.5 ml/min = xerostomia

Daily salivary output is estimated to be approximately 1 liter/day Flow rates can fluctuate by as much as 50% with diurnal rhythms.

Etiology

Etiology

Medications (especially selective serotonin reuptake inhibitors); in the geriatric population, drug induced xerostomia has been reported to contribute to difficulty with chewing, swallowing and denture retention. This may lead to avoidance of eating certain food. Ionizing radiation can injure the major and minor salivary glands which may lead to atrophy of the secretory components and results in varying degrees of temporary or permanent xerostomia.

Toxic substances in chemotherapeutic agents. Xerostomia has been reported in 45-60% of patients who developed chronic graft-vs.-host disease after undergoing allogenic bone marrow transplantation. Loss of saliva and a number of immunological abnormalities also have been implicated as possible complications of silicone breast implants.

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Oral Dryness in the Elderly

90 80 70 60 50 40 30 20 10 0 Normal Radiotx Sjogren Drugs
Subjective sensation of oral dryness in the elderly

Diagnosis

It has been estimated that a 50% reduction in salivary secretion needs to occur before the xerostomia becomes apparent. An affirmative response to at least one of the five following questions about symptoms has been shown to correlate with a decrease in salivary flow:

% Population

Questions:
1. 2. 3. 4. 5.

Warning Signs

Does your mouth usually feel dry? Does your mouth feel dry when eating a meal? Do you have difficulty swallowing dry food? Do you sip liquids to aid in swallowing dry food? Is the amount of saliva in your mouth too little most of the time, or dont you notice it?

Dry, burning mouth and throat Dry, cracking lips, especially in the corners. The cracks may be tender and/or bleed Problems with denture wearing Problems with eating and swallowing food Difficulty with speech due to mouth soreness Increased incidence of caries and periodontal disease

Types of Xerostomia

Medications Causing Xerostomia

True xerostomia (primary)- dysfunction of salivary glands due to local or systemic disease Pseudo xerostomia (secondary)- no changes of salivary glands; main reasons are changes in emotional state, psychotic states, and drugs

Anticholingergic Antidepressant Antihistamine Bronchodilator Diuretic Muscle Relaxant Sedative

Anti-inflammatory Antiacne Analgesic Anorexiant Antipsychotic Decongestant Anticonvulsant

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True Xerostomia

True Xerostomia

TYPE I- xerostomia, sometimes additionally with burning in mouth and throat. Without other symptoms in oral cavity.

TYPE II- xerostomia with atrophy inflammation of mouth mucosa

Depression Diseases with higher fever or other reasons causing dehydration. Salivary gland diseases (inflammation, Mikuliczs disease, atrophy after treatment with ionizing radiation) Arterial hypertension, arteriosclerosis Congenital lack of salivary glands

Atrophic inflammation of tongue Angular cheilitis Exfoliative cheilitis Burning of mouth and tongue Difficult in swallowing Gastritis Anemia Caries florida rapid loss of teeth

Xerostomia

Grading of Xerostomia

It affects 17-29% of sample populations based on self-reports or measurements of salivary flow rates. More prevalent in women. Can cause significant morbidity and a reduction in a patients perception of quality of life.

Grading based on subjective feeling of dry mouth only, is not sufficient enough to introduce proper treatment, because it may not correlate with objective function of salivary glands.

Flow rate of Saliva

Flow rate assessment

Measurement of flow rate of saliva allows monitoring of salivary glands and verify or change therapy. It is especially important in case of patients undergoing radiotherapy of neoplasms of head and neck and chemotherapy, when function of salivary glands changes during therapy.

Collect non stimulated saliva during 5 minutes. Quantitative assessment of saliva production is calculated as volume of saliva produced on average in one minute. Collect stimulated saliva (chewing a piece of paraffin) during 5 minutes. Collect saliva for 2 minutes after 20 seconds of activation with 4% citronic acid dropped on both sides of tongue.

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Flow rate assessment

Symptoms

When unstimulated salivary flow is less than 0.12 to 0.16 ml/minute, a diagnosis of hypofunction is established. Up till now there is no standard concerning salivary gland function tests. Therefore results cannot be compared between laboratories.

Dry mouth Frequent need of sipping water during eating or speaking Difficulty in chewing and swallowing Burning of tongue and/or lips Distaste (most often salty and bitter taste) Acute caries in atypical localization

Symptoms

Dryness of mouth

Decreased tolerance of prosthetics Dryness and irritation of throat Dryness of eyes Blurred vision Dryness of nose

Unpleasant breath More common secondary bacterial and fungal infections Higher risk of teeth demineralisation, crown and root caries, enamel erosions Inflammation of mucosa

Dryness of mouth

Management

Food sticking to teeth Difficulty in speaking Increase in saliva viscosity Changes in parodontium: gingivitis (accumulation of dental plaque) Decrease in quality of life

The general approach to treating patients with hyposalivation and xerostomia is directed at palliative treatment for the relief of symptoms and prevention of oral complications

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Symptomatic Treatment

Hygiene
Maintain good oral hygiene. Floss daily. Brush at least twice a day. Use special toothpaste: - with fluoride and alcohol free (e.g. Biotene toothpaste) - without detergents and sodium-laurylosulphate - often the same as for children Use chlorhexidin Fluoride prophylaxis

Sip water frequently all day long Let ice melt in the mouth Restrict caffeine intake Avoid mouth rinses containing alcohol Humidify sleeping area Coat lips with lubricant. Coat lips with a petroleum jelly like Vaseline, Blistex, or lanolin.

Advice for patients

Use topical fluoride. Apply moisturizing gels inside of the mouth (e.g. Biotene oral balance). Rinse with a recommended mouth rinse (e.g. Biotene mouth wash). Use an artificial saliva to moisten the mouth.

Diet

Diet

Restrict consumption of monosaccharides or substitute with aspartame, saccharine, acesulfam, sorbitol, xylitol Sugar free chewing gums Avoid eating foods that are dry, sour, spicy and increasing thirst

No alcohol No cigarettes Frequent drinking of water and other neutral non caffeine drinks Chewing lemon/orange peel

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Saliva Stimulants

Treatment

The use of sugar free gum, lemon drops or mints are conservative methods to temporarily stimulate salivary flow in patients with medication xerostomia or with salivary gland dysfunction.

Treatment of primary disease Verifying doses of drugs Swabbing with vitamin A+D solution Vitamin A, B, E Vitamin C

Treatment

Consult with physician to

decrease drug dose, alter drug dosages, or substitute one xerostomic medication for a similar-acting drug with fewer salivary side effects.

2% solution of potassium iodide (twice a day 1 teaspoon per os) Pilocarpine (3x/day 5 drops per os) Rinse with 1% Pilocarpine (15-20 drops in 1 glass of water) Pilocarpine HCl (Salagen) (1-2 tablets tid 1/2 hour prior to meals. Some authors recommend using 1 tablet of pilocarpine 4-5 times daily)

Pilocarpin HCl

Treatment

May need 2-3 months to determine effectiveness. Side effects include: sweating and diarrhea. Avoid use in patients with narrow angle glaucoma, severe asthma and pulmonary diseases.

Physostygmine It inhibits secretion of acetylocholinesterase, prolonging action of acetylocholine causing production of watery saliva.

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Treatment

Commercial Salivary Substitute

Artificial saliva: - Saliram lemon, Moi-Stir artificial Saliva, Salivart, Synthetic Saliva, Glandosane, Artisial, Saliment, Biotene Moisturising agent Oralbalance Saliva substitutes (with mucine or carboxymetylocellulose)

ex. Carboxymetylocelulosi 0,5% sol. D.S. for swabbing

Commercial oral moisturizing gels (OTC) includes: OralBalance XERO-Lube Salivart Moi-Stir Orex Optimoist

Oral Balance Ingredients

Polyglycerylmethacrylate (moisturizing agent) Lactoperoxidase (antibacterial) Glucose Oxidase (antibacterial) Lysozyme (antibacterial)

Treatment

Conditions

Saliva Stymulator (Biosonics Sal Salivaror System)

Electronic stimulator- stimulates receptors of touch, taste and muscle mechanoreceptors. It stimulates for 3 minutes, than turns off automatically and emits a signal. Stimulation depends on individual toleration. Patients are taught how to put electrodes on the tongue in 3 minutes cycle. Results positive in 50% cases.

Sjorgens syndrome Reumatoidal arthritis Lupus erythromatosus Crohns disease Primary Biliary Cirrhosis Graft vs host reaction Bone marrow transplantation Sarkoidosis

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Other Conditions

Diabetes type 1 or 2 Pancreas infections Hypertension Hyperthyroidism Chemotherapy HIV AIDS Vasculitis Chronic Active Hepatitis Renal Dialysis Stress and Depression