Xerostomia

Dry mouth commonly affects older patients and can reduce their quality of life, writes Mr Anish Shah.

Saliva has a crucial role in the maintenance of oropharyngeal health.

Dry mouth, or xerostomia, is more common in elderly patients

Dry mouth (xerostomia) or salivary hypofunction is more common in older patients. It can result in impairment of masticatory effectiveness, host defences and speech, which can potentially result in a reduction in quality of life.

It is estimated that 30 per cent of the population over the age of 65 have some degree of salivary hypofunction.1

There are many causes for dry mouth (see box).

Treating Xerostomia
General measures
  • Frequent sips of water (a small amount of lemon juice can help)
  • Use of sugar free chewing gum
  • Avoid caffeine
  • Avoid alcohol
  • Stop smoking
  • Avoid mouth breathing
  • Petroleum jelly to lips help reduce cracking
Specific measures
  • Drugs
  • If possible stop, reduce intake or switching to an alternative drug that does not cause xerostomia
  • Artificial saliva/stimulants
  • Saliva stimulant drugs - pilocarpine

Features and diagnosis
Aside from the obvious feature of a reduction in the amount of saliva production, several other features are often apparent in xerostomia cases (see box).

Some of these features may also lead to problems with the aerodigestive tract. Indigestion may occur and even colonisation of the lungs with Gram-negative anaerobes resulting in an increased susceptibility to aspiration pneumonia.2

Unstimulated normal salivary flow is approximately 0.3ml/min. This rate can drop to less than 0.1ml/min in those with xerostomia.

Stimulated salivary flow can be as much as 1-2ml/min. Patients with xerostomia may have a stimulated flow rate lower than 0.5ml/min.

Blood tests to rule out a systemic cause may be considered. These include an FBC, U&Es, LFTs, ferritin, folate, B12, glucose and rheumatoid factor.

Specific tests would also include antinuclear antibody (ANA) and serum angiotensin converting enzyme, and extractable nuclear antigen antibodies (SSA and SSB). Antibodies to extractable nuclear antigens are important markers for primary or secondary Sjogren's syndrome.

Treatment
Treatment of dry mouth depends on the diagnosis. This often involves a multidisciplinary team of clinicians.

General advice should consider things patients may have overlooked and is vital irrespective of the cause. Mouth spray or lozenges can offer relief for some patients (see box below).

Pilocarpine
Pilocarpine helps produce saliva via a parasympathetic stimulation pathway and thus can also produce parasympathetic-induced side-effects, for example, sweating, dizziness and blurred vision. A low dose is recommended initially.

Pilocarpine can work well when used in addition to the general measures outlined above.

  • Mr Shah is a specialist oral surgeon at Southend Hospital, Essex.
Dry Mouth
Causes
  • Sjogren's syndrome: primary/secondary
  • Diabetes
  • Hypothyroidism
  • Head and neck irradiation
  • Mumps (transient)
  • HIV/AIDS
  • Sarcoidosis
  • Amyloidosis
  • Haemochromatosis
  • Alcohol
  • Dehydration
  • Mouth breathing
  • Haemorrhage
  • Psychogenic: anxiety, depression
  • SOX syndrome: sialadenitis, osteoarthritis and xerostomia
  • Drugs: diuretics, tricyclic antidepressants, antihistamines, atropine, hyoscine, antipsychotics and some antiepileptic drugs
Clinical Features
  • Thicker saliva +/- the feeling of dysphagia
  • Masticatory function reduction
  • Mirror sticking phenomenon: mouth mirror sticks to buccal mucosa on examination
  • Burning sensation
  • Dry/cracked lips and dry red (occasionally lobulated) tongue
  • Root caries: protective mechanism of saliva on caries reduced
  • Salivary gland enlargement
  • Candidal infection

References

1. Ship JA, Pillemer SR, Baum BJ. Xerostomia and the geriatric patient. J Am Geriatric Soc 2002; 50(3): 535-43.

2. Loesche WJ, Bromberg J, Terpenning MS et al. Xerostomia, xerogenic medications and food avoidances in selected geriatric groups. J Am Geriatric Soc 1995; 43(4): 401-7.

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