Download Geriatric Dentistry

DIAGNOSIS AND MANAGEMENT
OF XEROSTOMIA IN THE
ELDERLY PATIENT
Salivary Gland Dysfunction
and Xerostomia (Dry Mouth)
XEROSTOMIA
• Xerostomia (dry mouth) is
defined as a subjective
complaint of dry mouth
that may result from a
decrease in the
production of saliva.
XEROSTOMIA
• It affects 17-29% of samples
populations based on self-reports
or measurements of salivary flow
rates.
• More prevalent in women.
• Can cause significant morbidity
and a reduction in a patient’s
perception of quality of life.
SALIVA
• It keeps the teeth healthy by
providing a lubricant, calcium
and a buffer.
• It also helps to maintain the
health of the gums, 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.
% Population
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
ml / min
Flow Rate of Saliva
0.5
0.4
0.3
0.2
0.1
0.0
unstimulated
stimulated
20-39 yr
40-59 yr
Age
> 60 yr
Antimicrobial Factors in
Human Whole Saliva
Non-immunoglobulin Factors
Lysozyme
Lactoferrin
Salivary peroxidase
SCNH2O2
Origin
Salivary glands, crevicular fluid (PMNs)
Salivary glands, crevicular fluid (PMNs)
Salivary glands
Salivary glands, crevicular fluid
Salivary glands, crevicular fluid (PMNs),
bacterial and yeast cells
Myeloperoxidase
Crevicular fluid (PMNs)
ClSalivary glands, crevicular fluid
Agglutinins, aggregating proteins
Salivary glands
Histidine-rich polypeptides
Salivary glands
Proline-rich proteins
Salivary glands
Immunoglobulin Factors
Secretory IgA
IgA, IgG, IgM
Salivary glands
Crevicular fluid
• 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 substanaces in
chemotherapeutic agents.
• Diabetes mellitus:
Patients
with poor glycemic control,
are more likely to complain of
xerostomia and may have
decreased salivary flow.
Dry Mouth With Strawberry Tongue
Severe Dry Mouth
(Strawberry Tongue)
Other Conditions
• Anxiety or Depression
• HIV
• Diabetes, Type 1 or 2
• AIDS
• Primary Biliary Cirrhosis
• Bone Marrow Transplantation
• Vasculitis
• Graft-vs.-Host Disease
• Chronic Active Hepatitis
• Renal Dialysis
Salivary Gland Dysfunction
and 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.
Pale Fisured Tongue Due To
Severe Dry Mouth
Moderate Xerostomia
Warning Signs in
Xerostomia
1.
2.
3.
Dry, burning mouth and throat
Dry, cracking lips, especially in
the corners. The cracks may
be tender and/or bleed
Problems with denture wearing
4. Problems eating and swallowing
food
5. Difficulty with speech due to
mouth soreness.
6. Increased caries and periodontal
disease
Diagnosis of Xerostomia
• 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:
1. Does your mouth usually feel
dry?
2. Does your mouth feel dry
when eating a meal?
3. Do you have difficulty
swallowing dry food?
4. Do you sip liquids to aid in
swallowing dry food?
•
5. Is the amount of saliva in your
mouth too little most
of the time, or don’t you notice
it?
When unstimulated salivary flow
is less than 0.12 to 0.16 ml/minute,
a diagnosis of hypofunction is
established.
MANAGEMENT
• 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:
• 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.
• Symptomatic Treatments:
• 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 the lips with a petroleum
jelly like Vaseline, Blistex, or
lanolin.
• Maintain good oral hygiene.
Floss daily.
• Brush at least twice a day.
• Use toothpaste with fluoride and
alcohol free (e.g. Biotene
toothpaste).
• Avoid Tobacco use, spicy, salty,
and highly acidic foods that
irritate the mouth.
Saliva Substitutes:
Rx:
Sodium carboxymethyl cellulose* 0.5%
aqueous solution [OTC]
Disp:8 fl. Oz.
Sig: Use as a rinse as frequently as needed.
*Generic carboxymethyl cellulose solutions
may be prepared by a pharmacist.
Commercial Salivary
Substitute
• Commercial oral moisturizing gels
(OTC) includes:
• OralBalance.
• XERO-Lube
• Salivart
• Moi-Stir Orex
• Optimoist
Commercial Oral Moisturizing
Gels [OTC]:
Laclede Oral Balance
Oral Balance Ingredients
•Polyglycerylmethacrylate
(moisturizing agent)
•Lactoperoxidase (antibacterial)
•Glucose Oxidase (antibacterial)
•Lysozyme (antibacterial)
Saliva Stimulants:
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.
Rx:
Biotine chewing gum [OTC]
Disp: 1 package
Sig: Chew as needed. Due to
problems of abrasion of the mucosa
under the denture and potential
adhesion of the gum to the denture,
use caution if the patient has
removable dentures.
Rx:
Pilocarpine HCl (Salagen) Tablets 5
mg
Disp: 21 tablets
Sig: Take 1 tablet tid 1/2 hour prior
to meals. Dose may be titrated to 2
tablets tid.
Some authors recommend using 1
tablet of pilocarpine 4-5 times daily.
Rx:
Pilocarpine HCL solution
1 mg/ml
Disp: 100 ml
Sig: Take 1 teaspoonful tid.
Pilocarpin HCl
• May need 2-3 months to determine
effectiveness.
• Side effects include sweating and
diarrhea.
• Avoid in patients with narrow angle
glaucoma, severe asthma, pulmonary
diseases.
Rx:
Cevimeline (Evoxac) Capsules 30 mg
Disp: 21 tablets
Sig: Take 1 tablet tid.
Rx:
Bethanechol (Urecholine) tablets
25 mg
Disp: 30 tablets
Sig: Take 1 tablet up to 5 times
daily.
Conditions Affecting the
Tongue
Conditions Affecting the
Tongue
•
•
•
•
•
Geographic tongue
Hairy tongue
Fissured tongue
Varices
Vitamin deficiencies
Benign Migratory Glossitis
(Geographic tongue)
• Etiology:
• Unknown
• May be associated with psoriasis and
Reiter’s syndrome.
• Appearances:
• Changing pattern of erythematous patches
on the tongue dorsum caused by atrophy
of the filiform papillae.
Geographic Tongue
Hairy Tongue
• Etiology:
•
•
•
•
•
Antibiotics
Tobacco
Chlorhexidine
Food debris
Oral candidiasis
Black/Brown Hairy Tongue
Brown Hairy Tongue
Hairy Tongue
• Treatment:
• Proper oral hygiene and tongue
brushing.
• If a fungal infection is suspected,
perform a fungal culture and use topical
antifungal.
Fissured Tongue
• Etiology:
• Unknown
• Appearance:
• Numerous small furrows and fissures on
the dorsum of the tongue. May be
attributed to trauma, vitamin deficiencies,
salivary gland dysfunction.
Nutritional Deficiencies
• Etiology
• Vitamin B1, B2, B6, B12 and folic acid
deficiency.
• Appearance
• Loss of filiform papillae produce a painful
erythematous and granular appearing
tongue.
• Eventually papillae atrophy leaving a
smooth/bald tongue.