The A to Z`s of Xerostomia in Older Adults

The A to Z’s of Xerostomia in Older Adults

Dry mouth, also known as xerostomia, is associated with a change in the volume and composition of saliva, which may be caused by medications, disease pathophysiology, and numerous other causes. Sometimes, the etiology of dry mouth is unclear. This condition can cause complications for older adults, such as dysphagia and periodontitis, which subsequently increase the risks of morbidity and mortality. As the population of adults aged 65 years and older continues to grow at an unprecedented rate in the United States, dry mouth will become an increasingly common condition seen by geriatricians and long-term care professionals. As such, knowledge of early identification and proper treatment of xerostomia is vitally important. Some studies have indicated that age per se does not seem to affect the salivary gland function.

In part 2 of this two-part Ask the Expert, Annals of Long-Term Care: Clinical Care and Aging (ALTC) discussed recognition and treatment of xerostomia in older adults with Driss Zoukhri, PhD, Professor, Department of Diagnosis and Health Promotion, and Mabi Singh, DMD, MS, Associate Professor, Department of Oral Pathology, Oral Medicine and Craniofacial Pain, Tufts University School of Dental Medicine, Boston, MA.  Part 1 focused on the diagnosis of Sjögren syndrome and the importance of recognizing its oral symptoms. Part 1 can be accessed here.

ALTC: When patients present with dry mouth, why is it important to identify the etiology of the patient’s dry mouth rather than simply treating it symptomatically?

Salivary gland hypofunction leading to dry mouth occurs in various conditions. Attempts to identify the cause of salivary hypofunction may lead to identification of other ailments that may prevail. The other potential causes of salivary hypofunction are water/metabolites loss (e.g., dehydration, impaired water intake, blood loss, emesis and diarrhea), renal water loss (polyuria, osmotic diuresis and protein calorie malnutrition), other autoimmune diseases (rheumatoid arthritis, systemic lupus erythematosus, Hashimoto’s thyroiditis, HIV infections), medications, autonomic dysfunction, conditions affecting the central nervous system, psychogenic disorders, trauma, decrease in mastication and diseases of salivary glands (sarcoidosis, hepatitis C, liver diseases, cystic fibrosis).

Why is dry mouth so common among older adults?

The life expectancy of Americans is increasing and they are prone to acute and chronic medical problems. Between 2007 and 2008, in older Americans above the age of 60 years, more than 76% used two or more medications. Most of these medications have anticholinergic properties. They compete with the neurotransmitter acetylcholine and block the neurotransmission process temporarily and decrease the capability of salivary gland cells to produce saliva by interfering to initiate and complete the saliva-making process. For example, diphenhydramine HCl, a common medication for allergy, acts by suppressing the release of acetylcholine, which results in suppression of neurotransmitters to the salivary glands and subsequently causes salivary gland hypofunction. Although older adults constitute only 13% of the total population, about one-third of all prescriptions are prescribed to them.

Also, the possibility of polypharmacy increases the anticholinergic load—the higher the anticholinergic index of a medication, the more unintended effect (ie, dry mouth). The most common medications with significant anticholinergic properties are first-generation antihistamines, antidepressants, antidiarrheals, muscle relaxants, antivertigo agents, tricyclic antidepressants, cardiovascular drugs, antispasmodics, antipsychotics, antiemetic agents, and urinary incontinence medications. The effect of combination of medications may be multiplied. However, the anticholinergic effect of medications are temporary and reversible and does not permanently damage the salivary gland cells.

Can you walk us through the process of diagnosing xerostomia in an older adult? Let’s start with the important notes from a patient’s medical history.

This would include history of any of the following: extreme fatigue, brain fog, repeated episodes of candidiasis, Raynaud’s phenomenon (a condition in which cold temperatures or strong emotions cause blood vessel spasms), waking up at night to drink water, constant sipping of water, needing water to aid swallowing food. It’s also important to note family members with autoimmune diseases. Underlying medical ailments (viz water/metabolite balance problemsrenal water loss, other autoimmune diseases medications, autonomic dysfunction, conditions affecting the central nervous system, psychogenic disorders, trauma, decrease in mastication and, diseases of the salivary glands) can be identified during patients medical history. Also, recurrent mucosal infections and lesions in the oral cavity may be indicative of salivary gland hypofunction. Medical history can indeed reveal whether the patient has been through therapeutic irradiation in the head and neck area, any chemotherapy and surgical procedures that potentially can compromise with the salivary gland function.

What about in your review of systems?

The patient may report a sensation in the eyes like “sandy” or “gritty,” or feeling there is a foreign-object in the eyes. Also, we look for dry skin, vaginal dryness, gastroesophageal reflux disease, recurrent chest infections, peripheral neuropathy, and Raynaud’s phenomenon. Fatigue is a cardinal symptom for xerostomic patients with Sjogren syndrome.

What are some significant findings on physical examination?

These findings may include decreased output from the salivary glands; mirror sticking to oral (buccal and tongue) mucosa; frothy, thick and viscous saliva; no salivary pooling on the floor of the mouth; fissuring or lobulated tongue; shortened papilla on tongue; altered gingival architecture; glassy appearance of the oral mucosa; and debris on palate or on teeth. Prevalence of multiple carious lesions on existing teeth and increased tooth surface loss, due to intrinsic and extrinsic erosion, and abrasions are observed in salivary hypofunction patients.

Is lab testing always warranted to diagnose xerostomia?

At Tufts University School of Dental Medicine, sialometry is done in all the patients. If evidence of salivary gland hypofunction is obtained and autoimmune diseases (eg, Sjӧgren syndrome) are suspected, then the serological tests (anti–Ro and anti-La) are done. Since serological tests are only about 60% sensitive, biopsy of minor salivary glands is requested to establish the diagnosis. Even though the minor salivary gland biopsy is considered the gold standard, there are variables that may contribute to misdiagnosis.

Is there a gold standard therapeutic regimen for treating xerostomia?
No, there are no evidence-based clinical practice guidelines or recommendations. The commonly used pharmacological agents used in the treatment of xerostomia are pilocarpine HCl, and cevimeline HCl. The most commonly used drugs to promote salivary secretion in the United States are pilocarpine HCl and cevimeline. These are parasympathomimetic drugs and muscarinic agonists.  The production of saliva is a result of their actions on especially M3 muscarinic receptors (and M1) and triggering the cascade of saliva production. The volume of saliva produced is dose-dependent and also depends on the remaining functional salivary glands. Because of the side effect of those agents and individual patient medical conditions, there may be limitations in prescribing them and titration of the dosage may be necessary.

What are the considerations for treating patients with drug-associated xerostomia?

Changing the drug or drugs for lesser anticholinergic load depends upon the condition of the patient (ie, if benefits of changing medications to decrease medication-induced xerostomia outweighs the risks). Since there is no physical damage to the salivary glands in medication-induced xerostomia and if the cause is the competitive antagonist characteristics of anticholinergic agents, the effect of anticholinergic medications can be overcome by mimicking the chewing process and through the usage of cholinergic agonists (eg, cevimeline HCl and pilocarpine HCl).

What are some other options for alleviating xerostomia discomfort?

Alternative methods such as acupuncture, electroacupuncture, low level laser therapy and herb therapies have been mentioned in the medical literature.Use of oil bath (sesame, coconut and olive), and breaking vitamin E caplets in the oral cavity may reduce symptomatic xerostomia by providing a lipid layer to prevent desiccation of the oral mucosa. Other methods of salivary gland stimulations are chewing gum (mechanical stimulation) and lozenges preferably with xylitol, massaging of the glands with the application of the moist heat, and using electric toothbrushes, sprays, and gel applications in the oral cavity. Increased humidity may help in preventing the dryness and evaporation of moisture from the oral, nasal and ocular surfaces if the humidity is maintained at 55% to 60% regardless of the ambient temperature. If there is nocturnal oral dryness, sleep pattern assessment should be done.

One recommendation for temporarily treating dry mouth is sipping water frequently, but this may not be the ideal solution at nighttime for elderly persons in long-term care because of the risk of falls associated with getting up at night to visit the bathroom. What do you recommend?

Big sips of water,although helps in hydrating the oral mucosa, will also wash away the protective agents in the saliva, including the proteins and mucins that gives the sensation of wetness in the oral cavity. So, big and frequent sips of water are not recommended but a small amount of water (just enough to wet and hydrate the oral mucosa) is recommended. To keep the mouth moist throughout the nighttime, breaking of vitamin E caplets in the mouth and application of oral rinses, oils, gels, sprays, and lubricants may help. If there is a problem with sleep (e.g. with open mouth) or breathing problems (e.g. blocked nose or DNS), they also need to be treated to prevent xerostomia at night.

What happens if the etiology of a patient’s xerostomia cannot be pinpointed?

Even if the etiology is not clear, if xerostomia is due to salivary gland hypofunction, the condition has to be treated to overcome the risk factors, decrease the occurrence of the complications of salivary gland hypofunction, and increase the quality of life of the patients.At Tufts, we treat the Sicca syndrome and Sjӧgren syndrome in pretty much same fashion.

What, if any, are the special considerations for managing dry mouth in patients with cognitive impairment, which is prevalent in long-term care settings?

There are several. First of all, anticholinergic effects of medications prescribed may increase a patient’s cognitive impairment. Thus, the risks and benefits of pharmacologically treating xerostomia in long-term care residents must be weighed carefully.

To control the carious lesions, professional dental examinations and cleanings should be conducted every 3 months as a standard of care. If new and recurrent carious lesions are found, they should be treated right away. Fluoride varnishes should be applied every 3 months during the prophylaxis, apart from daily usage of prescription strength fluoride toothpaste. Frequency of taking radiographs should be increased in those with high risk of developing carious lesions than in those with low risk of developing carious lesions.

Usage of supersaturated calcium and phosphate rinses may help with remineralizing and decrease the rate of demineralization of the calcified structures.Application of other remineralizing pastes directly on teeth may protect the teeth. Therapeutic usage of antimicrobials, such as chlorhexidine gluconate, may aid in reducing the noxious microorganisms. Controlling candidiasis, mechanically or therapeutically, may also reduce the burning sensation and/or unpleasant taste in the oral cavity as well as decrease the carious lesions. Lubricating agents also help in reducing discomfort.

Mechanical stimulation of the salivary glands with chewing gum containing xylitol not only stimulates saliva production but also controls the microbial population in the oral cavity.