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JADA Continuing Education

	ABSTRACT

TOP ABSTRACT EPIDEMIOLOGY OF DRY MOUTH... CLINICAL FINDINGS OF XEROSTOMIA... TREATING PATIENTS WITH... CONCLUSION REFERENCES

 
Background. The objective of this literature review is to summarize information about the etiology, diagnosis, oral sequelae and treatment of dry mouth in elderly patients.

Types of Studies Reviewed. The authors conducted a comprehensive review of the English-based scientific literature from the past 10 years. They selected the studies on the basis of clinical investigations to provide an objective assessment of dry mouth problems among older people.

Results. Dry mouth (salivary hypofunction, xerostomia) is a common problem among older people. It causes significant oropharyngeal disorders, pain and an impaired quality of life. Dry mouth has many causes, from local salivary disorders to a plethora of medications and medical conditions. Treatments are designed to correct the underlying cause and/or to enhance salivation with topical and systemic stimulants. Early intervention for dry mouth problems helps prevent the deleterious consequences of this disorder in elderly people.

Clinical Implications. Clinicians must be aware of dry mouth problems in older patients, and they should be prepared to provide a diagnosis and administer treatment to protect a patient’s oropharyngeal health and quality of life.

Key Words: Xerostomia; aging; saliva; salivary glands; Sjögren’s syndrome; cancer; radiotherapy; medications

Abbreviations: Anti-Ro/SSA: Anti-Ro/Sjögren’s Syndrome A autoantibodies • SS: Sjögren’s syndrome

Saliva plays a critical role in the preservation of oropharyngeal health. Complaints of a dry mouth (xerostomia) and diminished salivary output are common in older populations, which can result in impaired food and beverage intake, host defense and communication. Persistent xerostomia and salivary dysfunction can produce significant and permanent oral and pharyngeal disorders and can impair a person’s quality of life.

Salivary function remains remarkably intact in healthy older people, yet a plethora of systemic diseases (such as Sjögren’s syndrome [SS]), medications (such as anticholinergics) and head and neck radiotherapy (such as for cancer) cause xerostomia, particularly in elderly patients. Treatment strategies include salivary replacement therapies, as well as use of gustatory, masticatory and pharmacological stimulants.

	EPIDEMIOLOGY OF DRY MOUTH IN ELDERLY PEOPLE

TOP ABSTRACT EPIDEMIOLOGY OF DRY MOUTH... CLINICAL FINDINGS OF XEROSTOMIA... TREATING PATIENTS WITH... CONCLUSION REFERENCES

 
Estimates of xerostomia and salivary gland hypofunction are difficult to obtain owing to the limited number of epidemiological studies that have been conducted; however, Ship and colleagues¹ estimated that approximately 30 percent of the population 65 years and older experience these disorders. Drug-induced dry mouth is the most common cause, because the vast majority of older adults are being treated with at least one medication that causes salivary hypofunction. The prevalence of xerostomia is nearly 100 percent among patients with SS,² and head and neck radiation for the treatment of cancer causes permanent xerostomia.³

Dry mouth in elderly people. Many older adults experience dry mouth for a variety of reasons.^4,5 Interestingly, output from the major salivary glands does not undergo clinically significant decrements in healthy older people.⁶ Some data show age-related changes in salivary constituents, but other evidence shows age-stable production of salivary electrolytes and proteins in the absence of major medical problems and medication use. Clinicians should not attribute complaints of a dry mouth and findings of salivary hypofunction in an older person to his or her age; an appropriate diagnosis is required.

Drugs with anticholinergic effects are the most likely to produce complaints of dry mouth and diminished salivary output.

Salivary disorders in the aging population usually are caused by systemic diseases and their treatments (for example, anticholinergic medications or radiation therapy). Numerous medical conditions (such as SS, diabetes, Alzheimer’s disease, dehydration), medications (both prescription and non-prescription), head and neck irradiation and chemotherapy can cause or contribute to salivary gland diseases.^1–3,5 Furthermore, evidence suggests that salivary glands are vulnerable to the deleterious effects of all of these conditions in elderly people,⁷ which may contribute to the increased prevalence of salivary problems with age.

Medications. The most common cause of salivary disorders is the use of prescription and non-prescription medications. For example, Sreebny and Schwartz⁸ reported that 80 percent of the most commonly prescribed medications cause xerostomia, with more than 400 medications associated with salivary gland dysfunction as an adverse side effect. Because elderly people are more likely than the rest of the population to take medications and are more vulnerable to their side effects, medication-induced xerostomia is common.^4,9,10

Drugs with anticholinergic effects are the most likely to produce complaints of dry mouth and diminished salivary output. Furthermore, drugs that inhibit neurotransmitters from binding to salivary gland membrane receptors, or that perturb ion transport pathways in the acinar cell, may affect adversely the quality and quantity of salivary output. Common categories of these drugs include tricyclic antidepressants, sedatives and tranquilizers; antihistamines; antihypertensives ( and ß blockers, diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors); cytotoxic agents; and anti-Parkinsonism and antiseizure drugs.

Chemotherapeutic agents also have been associated with salivary disorders.¹¹ After completing therapy, most patients experience a return of salivary function to prechemotherapy levels; however, long-term changes in salivary function have been reported.¹² Radioactive iodine (I-131), which is used to treat thyroid malignancies, damages salivary tissues in a dose-dependent fashion, primarily affecting the parotid glands.^5,13

Radiation therapy. A common therapy for head and neck cancers is external beam radiation, which causes severe and permanent salivary hypofunction and results in persistent complaints of xerostomia.³ Radiation-induced destruction of the serous-producing salivary cells occurs via a process termed "apoptosis." Within one week of the start of irradiation (after 10 grays of radiation have been delivered), a patient’s salivary output declines by 60 to 90 percent, with no recovery occurring unless the total dose to salivary tissues is less than 25 Gy.¹⁴ Most patients receive therapeutic dosages that exceed 60 Gy, and their salivary glands undergo atrophy and become fibrotic. These patients experience a plethora of oral and pharyngeal side effects as a result of the salivary dysfunction (Box).

View this table: [in this window] [in a new window]   BOX Oral and pharyngeal effects of salivary hypofunction.

 
SS. SS is one of the most frequently encountered chronic autoimmune connective-tissue disorders, and it is the most common systemic condition associated with xerostomia and salivary dysfunction. SS occurs in primary and secondary forms. Patients with primary SS have salivary and lacrimal gland involvement, with an associated decreased production of saliva and tears. In secondary SS, the disorder occurs with other autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, sclero-derma, polymyositis and polyarteritis nodosa.^2,15

The onset of the disease often is insidious; accordingly, diagnosis may be delayed for many years. The female-to-male ratio has been estimated to be 9:1, although reported ratios vary considerably. The prevalence of primary SS varies from 0.05 to 4.8 percent,¹⁶ with approximately 1 million people in the United States estimated to have the disease.

The pathogenesis of SS remains unclear.² Environmental agents (for example, viruses) may trigger events in a genetically susceptible host. Hormonal factors may play a role in the pathogenesis, because SS occurs predominantly in women. SS probably has a genetic component, because SS autoantibodies (for example, anti-Ro/Sjögren’s Syndrome A autoantibodies [anti-Ro/SSA]) are higher in family members of patients with the disease than they are in the general population.¹⁷

Typical oral findings in patients with SS and xerostomia are described below for other xerostomic patients (Box). In addition, diminished tear production causes punctuate ulcerations of the ocular surface termed "keratoconjunctivitis sicca." Other systemic findings include synovitis, neuropathy, vasculitis and disorders of the skin, thyroid gland, urogenital system and respiratory and gastrointestinal tracts. Most serious is the estimated 44-fold increase in the prevalence of B-cell lymphomas among patients with SS.¹⁸ Laboratory test results frequently will be positive for rheumatoid factor (90 percent of cases), anti-Ro/SSA or anti-La/Sjögren’s Syndrome B auto-antibodies (50 to 90 percent of cases), with the presence of increased serum immunoglobulins.¹⁹

	CLINICAL FINDINGS OF XEROSTOMIA AND SALIVARY HYPOFUNCTION

TOP ABSTRACT EPIDEMIOLOGY OF DRY MOUTH... CLINICAL FINDINGS OF XEROSTOMIA... TREATING PATIENTS WITH... CONCLUSION REFERENCES

 
Saliva is essential for the preservation of oropharyngeal health, and it serves many functions in the oral and gastrointestinal environment. Saliva aids in swallowing, oral cleansing, speech, digestion and taste. When salivary hypofunction and xerostomia occur, transient and permanent oral and extraoral disorders can develop (Figure 1).

View larger version (81K): [in this window] [in a new window]   Figure 1. Plaque and calculus accumulations in a patient with severe salivary hypofunction and xerostomia.

 
Patients with salivary hypofunction experience numerous oral symptoms. Nighttime xerostomia is common in these patients, because salivary output typically reaches its lowest circadian levels during sleep, and the problem may be exacerbated by mouth breathing. Taste may be disturbed, as saliva stimulates gustatory receptors located on the taste buds and delivers tastants directly to the taste buds. Patients with chronic xerostomia secondary to SS, head and neck radiotherapy and other conditions experience a diminished ability to detect and recognize many gustatory stimuli.²⁰

Saliva also is necessary to prepare food for digestion and deglutition. Patients with low salivary flow have difficulty masticating and swallowing, particularly dry foods, and they may need liquids to swallow food (Box). These problems can lead to changes in food and fluid selection that may compromise nutritional status. They also can lead to an increased susceptibility to aspiration pneumonia, with consequent colonization of the lungs with gram-negative anaerobes from the gingival sulcus.²¹

Dentures. The lack of saliva and lubrication in the denture-mucosal interface can produce denture sores, and retention of prostheses may be reduced when the salivary film is inadequate. Subjective complaints of halitosis, stomatodynia (burning mouth and tongue) and intolerance to acidic and spicy foods also have been reported.²² Oral mucosal surfaces (that is, tongue, buccal mucosa, floor of the mouth, palate, posterior oral pharynx) become desiccated and friable. The subsequent speech and eating difficulties that may develop can impair social interactions and may cause some patients to avoid social engagements.

Patients with salivary hypofunction are more susceptible to developing mucosal candidiasis, which can present with a pseudomembrane, erythema of the underlying tissues and/or a burning sensation of the tongue or other intraoral soft tissues (Figure 2). Fungus-associated denture stomatitis usually is diagnosed on the basis of clinical findings, although microscopy can confirm the clinical diagnosis via the observation of mycelia or pseudohyphae in a direct smear. Candida may colonize the corners of the mouth extraorally (angular cheilitis) in the areas where the lips are cracked and dry.

View larger version (123K): [in this window] [in a new window]   Figure 2. Pseudomembraneous candidiasis plaques on the tongue of a patient with salivary hypofunction and xerostomia.

 
Dental caries. A second frequently occurring infection is new and recurrent dental caries (Figure 3). This condition is particularly common among older adults, many of whom now have more retained natural teeth, a high number of previously restored dental surfaces and gingival recession predisposing teeth to root-surface caries. Without sufficient saliva to restore the oral pH and regulate bacterial populations, the mouth is colonized rapidly with caries-associated microorganisms.

View larger version (97K): [in this window] [in a new window]   Figure 3. New and recurrent dental caries in a patient who received head and neck radiotherapy for a squamous cell carcinoma of the tongue. The patient experienced permanent loss of salivary function and xerostomia.

 
Visible and palpable enlarged major salivary glands develop if salivary glands are infected or obstructed, such as in bacterial parotitis or mumps. Patients with SS may develop salivary enlargements, with or without an accompanying infection. A swollen parotid gland can displace the earlobe and extend inferiorly over the angle of the mandible, whereas an enlarged sub-mandibular gland is palpated medial to the posteroinferior border of the mandible.

	TREATING PATIENTS WITH XEROSTOMIA

TOP ABSTRACT EPIDEMIOLOGY OF DRY MOUTH... CLINICAL FINDINGS OF XEROSTOMIA... TREATING PATIENTS WITH... CONCLUSION REFERENCES

 
The first step in treating patients with xerostomia is establishing a diagnosis. This frequently involves a multidisciplinary team of health care practitioners among whom communication is critical, because many older people have concomitant medical problems and polypharmaceutical complications. The second step is to schedule frequent dental evaluations to assess patients for oral complications of low salivary output.^22,23 A low-sugar diet and daily use of topical fluorides and antimicrobial mouthrinses are critical to help prevent dental caries (Table²⁴). Dry mucosal surfaces and dysphagia are treated with oral moisturizers and lubricants, artificial salivas and nighttime use of bedside humidifiers. Clinicians must instruct patients to drink fluids while eating, particularly if foods are dry and rough.

View this table: [in this window] [in a new window]   TABLE Treatment of xerostomia-associated problems.*

 
For patients with remaining viable salivary gland tissue, stimulation techniques are helpful. Sugar-free chewing gum, candies and mints can stimulate salivary output. The U.S. Food and Drug Administration has approved two secretagogues, pilocarpine^25,26 and cevimeline,^27,28 for the treatment of xerostomia and salivary hypofunction. These drugs are effective in increasing secretions and diminishing xerostomic complaints in patients with sufficient exocrine tissue. Pilocarpine is a non-selective muscarinic agonist, whereas cevimeline reportedly has a higher affinity for M1 and M3 muscarinic receptor subtypes. Because M2 and M4 receptors are located on cardiac and lung tissues, cevimeline treatment, in theory, should enhance salivary secretions while diminishing adverse effects on pulmonary and cardiac function.

Oral candidiasis is a frequent complication of dry mouth and most commonly is treated with topical antifungal agents (Table). Oral rinses, ointments, pastilles and troches are effective for most forms of oral candidiasis, and systemic antifungal therapy (for example, ketoconazole, fluconazole) should be reserved for refractory disease and for patients who are immunocompromised. Dentures may harbor fungal infections and thus require immersion once or twice daily in solutions containing benzoic acid, 0.12 percent chlorhexidine or 1 percent sodium hypochlorite. Daily denture hygiene and use of topical antifungal ointment also are helpful. Clinicians should treat patients who have angular cheilitis with a combination of antifungal and anti-inflammatory agents.

Drug substitutions may help reduce the adverse side effects of medications that produce xerostomia if similar drugs are available that have fewer xerostomic side effects. For example, Scully²⁹ reported that selective serotonin reuptake inhibitors cause less dry mouth than do tricyclic antidepressants.

If an older patient can take anticholinergic medications during the daytime, nocturnal xerostomia can be diminished, because salivary output is lowest at night.⁸ In addition, if a patient can divide his or her drug dosages, he or she may be able to avoid the side effects caused by a large single dose. A dentist’s scrutiny of drug side effects can assist in diminishing the xerostomic potential of many pharmaceuticals used by elderly patients.

	CONCLUSION

TOP ABSTRACT EPIDEMIOLOGY OF DRY MOUTH... CLINICAL FINDINGS OF XEROSTOMIA... TREATING PATIENTS WITH... CONCLUSION REFERENCES

 
Complaints of a dry mouth (xerostomia) and diminished salivary output (salivary hypofunction) are common in elderly people as a result of a plethora of salivary gland disorders, medication use and medical disorders. Dry mouth problems have a clinically significant deleterious impact on oropharyngeal health. Clinicians must be able to diagnose dry mouth disorders in their elderly patients and provide preventive and interventional treatments to reduce the impact of these disorders on an older person’s quality of life.

	FOOTNOTES

Dr. Ship is a professor, Department of Oral and Maxillofacial Pathology, Radiology, and Medicine, New York University College of Dentistry; a professor, Department of Medicine, New York University School of Medicine; and director, Bluestone Center for Clinical Research, New York University College of Dentistry, 421 First Ave., 2nd Floor, New York, N.Y. 10010-4086, e-mail "jonathan.ship{at}nyu.edu". Address reprint requests to Dr. Ship.

	REFERENCES

TOP ABSTRACT EPIDEMIOLOGY OF DRY MOUTH... CLINICAL FINDINGS OF XEROSTOMIA... TREATING PATIENTS WITH... CONCLUSION REFERENCES

 

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