JADA Continuing Education
How can oral health care providers determine if patients have dry mouth?
MAHVASH NAVAZESH, D.M.D.
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ABSTRACT
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Background. Dentists recognize the importance of saliva in maintaining oral health and often are familiar with the clinical effects an insufficient salivary flow can have on oral tissues. A variety of medical conditions and medications can alter salivary secretion and composition. Typically, diagnosis of hyposalivation is made only after damage has occurred to the oral tissues.
Overview. The author describes a series of clinical steps that, if followed properly, may help in the early detection of salivary gland hypofunction and prevention of its severe complications. This four-step approach includes identifying a patient’s chief complaint and the symptoms and duration of illness that brought the patient to the dentist, as well as any approaches the patient took to relieve symptoms; obtaining a medical history that includes a review of the body systems; performing a clinical evaluation that notes the patient’s overall condition in addition to the health and functioning of the salivary glands and oral soft and hard tissues; and, when needed, conducting further diagnostic evaluations.
Conclusions and Clinical Implications. Oral health care providers will continue to face the challenges of treating new and recurrent carious lesions if the profession’s approach to salivary hypofunction remains reactive rather than proactive. The recommendations in this article may enhance clinicians’ awareness of the objective methods used to identify patients with salivary gland hypofunction or those at risk of developing it. It is hoped that early identification of asymptomatic patients at risk of developing hyposalivation, as well as symptomatic patients will lower the incidence and prevalence of dental caries and fungal infections in this population and ultimately enhance their quality of life.
Xerostomia (the subjective complaint of dry mouth) and salivary gland hypofunction (objective evidence of low saliva secretion) have been the focus of many reports within the past 20 years.1–15 Scientific evidence supports the following observations:
- – Saliva plays a significant role in the maintenance of oral and general health.
- – A variety of medical conditions and medications alter salivary secretion and composition.
- – Xerostomia and salivary gland hypofunction are common clinical findings.
- – Aging per se has no significant clinical impact on salivary secretion.
- – The most common cause of salivary gland hypofunction in the elderly population is medication use.
- – Xerostomia and salivary gland hypofunction are not always present simultaneously.
- – Dental caries and oral fungal infections are the most common complications associated with salivary gland hypofunction.
- – Xerostomia and salivary gland hypofunction affect the quality of life.
A series of clinical steps may help in the early detection of salivary gland hypofunction and prevention of its severe complications.
The significant contributory role of saliva in oral soft- and hard-tissue protection, tooth remineralization, digestion and alimentation is known to oral health care providers.16–23 However, these contributions often are taken for granted by other health care providers, health insurance carriers and the public. Therefore, dentists and hygienists often are faced with the irreversible consequences of a lack of, or diminished amount of, saliva secretion and are forced to intervene via surgical approaches (that is, restorative or endodontic treatment, implant placement) and to face treatment failure (for example, recurrent dental caries) despite administering excellent dental care.
Dental caries is one of the most prevalent oral infectious diseases in humans and the most common complication associated with salivary gland hypofunction. For the geriatric population, the need for operative and restorative treatment will continue to increase, and oral health care providers will continue to face the challenges of treating new and recurrent carious lesions if their approach remains reactive rather than proactive.
In this article, I describe a series of clinical steps that, if followed properly, may help in the early detection of salivary gland hypofunction and prevention of its severe complications.
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PATIENT’S CHIEF COMPLAINT AND HISTORY OF ILLNESS
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Unfortunately, most health questionnaires do not include specific questions about dry mouth; therefore, the condition may go unnoticed if the patient is asymptomatic (has no complaints). Regardless of the complaint that brings the patient to the dental office, the following questions have been shown to help identify people with, or at risk of developing, salivary gland hypofunction24:
- – Does the amount of saliva in your mouth seem to be too little, too much or you do not notice it?
- – Do you have any difficulties swallowing?
- – Does your mouth feel dry when eating a meal?
- – Do you sip liquids to aid in swallowing dry food?
A "yes" response to "too little saliva" in the first question is an indication of reduced unstimulated saliva. A "yes" response to any of the last three questions is an indication of reduced stimulated saliva. These questions can be used to identify patients who are currently asymptomatic, but are at risk of developing complications of reduced saliva secretion.
For symptomatic patients—those who come to the dental office with a complaint of dry mouth—it is best to document the onset, frequency and severity of the dry-mouth condition. A visual analogue scale, or VAS, can be used to assess the severity at the initial visit and to evaluate the patient’s response to recommended therapy at subsequent visits. VAS is commonly used in the assessment of pain,25–27 but also can be used to assess salivary-related complaints.
Dentists or designated staff members ask patients a series of questions and instruct them to mark their responses to each question by placing vertical lines on a 100-millimeter horizontal scale. The scale is labeled at both ends. One end represents the maximum intensity or frequency of the presenting condition, and the other end represents the absence of the condition. For example, if a patient is asked to rate dryness of the mouth, the scale is labeled "not dry at all" at one end and "very dry" at the other end. If the patient places his or her mark in the middle of the line, a score of 50 mm would be given for dryness. The practitioner then compares future scores with this baseline score to determine if the patient’s condition is improving or worsening.
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MEDICAL HISTORY AND REVIEW OF BODY SYSTEMS
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Although oral health care providers routinely obtain and document a patient’s medical history, evaluating salivary gland function is not a common practice unless the patient is symptomatic. When reviewing a patient’s medical history, dentists should keep in mind these facts28–32:
- – Salivary secretion is affected by the nature, severity, number and duration of a variety of medical disorders and medications.
- – Women are more susceptible than men to certain medical conditions known to affect salivary secretion (for example, Sjögren’s syndrome, rheumatoid arthritis, scleroderma, hypothyroidism, depression, eating disorders).
- – Nutritional and dietary habits, as well as oral hygiene practices, have a profound impact on the pattern and severity of oral complications of salivary gland hypofunction.
- – Tobacco, alcohol and recreational drugs may affect the quality or quantity of saliva.
Even in the absence of a dry mouth complaint, practitioners should consider the above points and anticipate the potential for hyposalivation as well as future oral complications if no intervention is made early. Unlike a medical history that provides information about known medical conditions, a history that includes a review of the body systems may uncover signs and symptoms of medical conditions and behaviors that have gone unnoticed or undiagnosed.
For example, a patient may not volunteer information about difficulty in swallowing, a hoarse voice, a dry throat, frequent hunger or thirst, dry eyes or painful joints, unless the oral health care provider specifically asks about them. A review of body systems can lead to early detection and eventual diagnosis of medical conditions (for example, Sjögren’s syndrome, diabetes, depression) that may lead to salivary gland hypofunction and its complications.
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CLINICAL EVALUATION
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The clinical evaluation should include an overall impression of the patient, as well as an evaluation of the salivary glands and oral soft and hard tissues. The clinician should pay special attention to the patient’s physical and emotional makeup. For example, does the patient look anorexic, bulimic, depressed, anxious, malnourished or obese, or does he or she appear to be under the influence of medication?28,33–35
Evaluation of the salivary glands should include documentation of any of the following findings: enlargement, tenderness on palpation, lack of or diminished saliva on palpation, contaminated saliva (with blood or pus) on palpation, atrophic Stensen’s and Wharton’s duct papillae, and absence of a salivary pool.
The soft-tissue examination should focus on the presence of the following conditions: dry, desiccated, atrophic, fissured, lobulated or discolored mucosa. In addition to conducting visual inspections, the dentist can use a tongue blade to assess tissue dryness. To do so, he or she places a dry tongue blade against the buccal mucosa; if the tongue blade adheres to the mucosa while the dentist attempts to lift it away, this is an indication of tissue dryness and reduced salivary secretion (Figure 1
).
The hard-tissue examination will reveal treated and untreated caries, as well as the location and severity of new and recurrent carious lesions.
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FURTHER DIAGNOSTIC EVALUATIONS
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The nature of information gathered during steps 1 through 3 above will dictate the need for any further evaluations. Use of a questionnaire or flowchart (Figure 2) can be helpful in identifying and developing a treatment plan for patients with, or at risk of developing, hyposalivation. Typically, a single test or a combination of diagnostic tests (for example, sialometric, microbial, serologic and histologic tests and imaging studies) will be indicated to establish a final diagnosis before treatment planning can begin. Sialometric (whole-saliva collection) and histologic (minor salivary gland biopsy) tests routinely are performed by dentists for the diagnosis of medical conditions such as Sjögren’s syndrome, sarcoidosis and other connective-tissue disorders.
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Figure 2. Flowchart identifying patients at risk of developing salivary gland hypofunction and its complications. Adapted with permission of the publisher by Navazesh and colleagues.4
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Sialometric evaluations.
Although sialometry usually is performed in academic settings, it can be a useful tool for private practitioners to identify patients with salivary gland disorders.
Unstimulated saliva.
Collecting whole saliva is easier and more cost-effective than collecting saliva from an individual gland (parotids, submandibular/sublingual) in a private practice setup. Whole saliva can be collected under unstimulated (resting) and stimulated conditions. Patients are instructed not to drink, eat, smoke, perform oral hygiene or put anything into their mouths for 90 minutes before the collection time. The dentist or designated staff member collects the saliva in a quiet environment, with the patient sitting in an upright position, head tilted forward and eyes open, with minimal body and orofacial movements (Figure 3, page 617). The patient is asked to swallow saliva first, then stay motionless and allow the saliva to drain passively for five minutes over the lower lip into a preweighed test tube fitted with a funnel. After the five-minute collection period, the oral health care provider asks the patient to void the mouth of saliva by spitting into the funnel.
Stimulated saliva.
The clinician then collects stimulated saliva by asking the patient to chew on a piece of gum at approximately 45 chews per minute. The patient will void the mouth of saliva by spitting into the collection tube every minute for a total of five minutes. The clinician then calculates the salivary flow rate by dividing the amount (weight or volume) of collected saliva by the duration of the collection period (five minutes).
There is no general agreement about what constitutes a normal salivary flow rate; however, researchers generally consider an unstimulated flow rate of 0.1 to 0.2 milliliters per minute (or grams per minute) and a chewing stimulated flow rate of 0.7 mL/minute (or g/minute) to be abnormally low flow rates.36–38 Currently, clinicians use a 0.1-mL/minute unstimulated whole-saliva flow rate as a criterion for the diagnosis of Sjögren’s syndrome.36–38
Minor salivary gland biopsy.
Histopathologic changes involving the major or minor salivary glands may indicate local or systemic conditions that affect salivary gland secretion. Clinicians can perform a minor salivary gland biopsy in the dental office (using local anesthetic) based on the patient’s medical status and the clinician’s expertise. The common site for a minor salivary gland biopsy is the inner aspect of the lower lip (Figure 4). The histologic changes caused by local or systemic conditions may be reversible or irreversible. For example, the inflammatory changes caused by most xerogenic medications are transient in nature and will decrease in intensity once the medication is discontinued.
However, changes associated with some medical conditions (for example, Sjögren’s syndrome) are more permanent in nature. Clinicians use the intensity of lymphocytic infiltration of the minor salivary glands as a criterion for the diagnosis of Sjögren’s syndrome. Clusters of 50 lymphocytes are referred to as foci; the presence of two foci in a 4- x 4-millimeter section of tissue (obtained via a biopsy) is considered diagnostic for Sjögren’s syndrome. Management of salivary gland hypofunction, which includes hydration, salivary gland stimulation (that is, masticatory, gustatory, pharmacotherapeutic), saliva substitution, and antimicrobial and fluoride therapy, has been reviewed extensively elsewhere.10,39–47
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CONCLUSION
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During the past several years, oral health care providers have been making increasingly significant contributions to the diagnosis and management of medical and craniofacial disorders. As patient management shifts from surgical to preventive models, the detection, recognition and prevention of salivary gland hypofunction using risk assessment will become more important. This article has aimed to enhance clinicians’ awareness of objective methods for identifying patients with, or at risk of developing, salivary gland hypofunction. I hope that early identification of asymptomatic at-risk patients and symptomatic patients will lower the incidence and prevalence of dental caries and fungal infections in this population and ultimately enhance their quality of life.
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Dr. Navazesh is a member of the ADA Council on Scientific Affairs and is an associate professor and chair, Division of Diagnostic Sciences, University of Southern California, School of Dentistry, 925 W. 34th St., Room 4320, Los Angeles, Calif. 90089-0641, e-mail "navazesh{at}usc.edu". Address reprint requests to Dr. Navazesh.
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FOOTNOTES
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"Practical Science" is prepared each month by the ADA Council on Scientific Affairs and Division of Science, in cooperation with The Journal of the American Dental Association. The mission of "Practical Science" is to spotlight what is known, scientifically, about the issues and challenges facing today’s practicing dentists.
Although the Practical Science feature is developed in cooperation with the ADA Council on Scientific Affairs and the Division of Science, the opinions expressed in this article are those of the author and do not necessarily reflect the views and positions of the Council, the Division or the Association.
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ABSTRACT
PATIENT’S CHIEF COMPLAINT...
