Dry mouth and its effects on the oral health of elderly people pptx

Background. The objective of this literature review is to summarize information about the eti- ology, diagnosis, oral sequelae and treatment of dry mouth in elderly patients. Types of Studies Reviewed. The authors con- ducted 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 condi- tions. Treatments are designed to correct the underlying cause and/or to enhance salivation with topical and systemic stimulants. Early interven- tion for dry mouth problems helps prevent the deleterious consequences of this disorder in elderly people. Clinical Implications. Clinicians must be aware of dry mouth prob- lems 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. JADA 2007;138(9 supplement):15S-20S. S aliva 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 bev- erage intake, host defense and com- munication. Persistent xerostomia and salivary dysfunction can pro- duce 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 syn- drome [SS]), medications (such as anticholinergics) and head and neck radiotherapy (such as for cancer) cause xerostomia, particularly in elderly patients. Treatment strate- gies include salivary replacement therapies, as well as use of gusta- tory, masticatory and pharmacolog- ical stimulants. EPIDEMIOLOGY OF DRY MOUTH IN ELDERLY PEOPLE Estimates of xerostomia and sali- vary gland hypofunction are diffi- cult to obtain owing to the limited number of epidemiological studies ABSTRACT A R T I C L E 2 Dr. Turner is an assistant professor, Department of Oral and Maxillofacial Surgery, New York University College of Dentistry, New York City. 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@nyu.edu”. Address reprint requests to Dr. Ship. J A D A C O N T I N U I N G E D U C A T I O N ✷ ✷ ® Dry mouth and its effects on the oral health of elderly people Michael D. Turner, DDS, MD; Jonathan A. Ship, DMD, FDS RCS (Edin) JADA, Vol. 138 http://jada.ada.org September 2007 15S Copyright ©2007 American Dental Association. All rights reserved. that have been conducted; however, Ship and col- leagues 1 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 per- cent among patients with SS, 2 and head and neck radiation for the treatment of cancer causes per- manent xerostomia. 3 Dry mouth in elderly people. Many older adults experience dry mouth for a variety of rea- sons. 4,5 Interestingly, output from the major sali- vary glands does not undergo clinically significant decrements in healthy older people. 6 Some data show age-related changes in salivary con- stituents, 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 diag- nosis is required. Salivary disorders in the aging population usually are caused by systemic diseases and their treat- ments (for example, anticholinergic medications or radiation therapy). Numerous medical conditions (such as SS, diabetes, Alzheimer’s disease, dehy- dration), 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 delete- rious 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 sali- vary disorders is the use of prescription and non- prescription medications. For example, Sreebny and Schwartz 8 reported that 80 percent of the most commonly prescribed medications cause xerostomia, with more than 400 medications asso- ciated 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 per- turb 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; antihyperten- sives (α and β blockers, diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors); cytotoxic agents; and anti- Parkinsonism and antiseizure drugs. Chemotherapeutic agents also have been asso- ciated with salivary disorders. 11 After completing therapy, most patients experience a return of sali- vary function to prechemotherapy levels; however, long-term changes in salivary function have been reported. 12 Radioactive iodine (I-131), which is used to treat thy- roid malignancies, damages sali- vary 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 sali- vary hypofunction and results in persistent com- plaints of xerostomia. 3 Radiation-induced destruc- tion of the serous-producing salivary cells occurs via a process termed “apoptosis.” Within one week of the start of irradiation (after 10 grays of radia- tion have been delivered), a patient’s salivary output declines by 60 to 90 percent, with no recovery occurring unless the total dose to sali- vary 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). SS. SS is one of the most frequently encoun- tered chronic autoimmune connective-tissue dis- orders, and it is the most common systemic condi- tion associated with xerostomia and salivary dysfunction. SS occurs in primary and secondary 16S JADA, Vol. 138 http://jada.ada.org September 2007 Drugs with anticholinergic effects are the most likely to produce complaints of dry mouth and diminished salivary output. ABBREVIATION KEY. Anti-Ro/SSA: Anti-Ro/Sjögren’s Syndrome A autoantibodies. SS: Sjögren’s syndrome. Copyright ©2007 American Dental Association. All rights reserved. forms. Patients with primary SS have salivary and lacrimal gland involvement, with an asso- ciated 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 esti- mated to be 9:1, although reported ratios vary considerably. The prevalence of primary SS varies from 0.05 to 4.8 percent, 16 with approxi- mately 1 million people in the United States esti- mated 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 patho- genesis, 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 xeros- tomic 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 Lab- oratory 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 Saliva is essential for the preservation of oropha- ryngeal health, and it serves many functions in the oral and gastrointestinal environment. Saliva aids in swallowing, oral cleansing, speech, diges- tion and taste. When salivary hypofunction and xerostomia occur, transient and permanent oral and extraoral disorders can develop (Figure 1). 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 exac- erbated by mouth breathing. Taste may be dis- turbed, 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 radio- therapy and other conditions experience a dimin- ished ability to detect and recognize many gusta- tory stimuli. 20 Saliva also is necessary to prepare food for digestion and deglutition. Patients with low sali- vary flow have difficulty masticating and swal- lowing, 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 gin- gival sulcus. 21 Dentures. The lack of saliva and lubrication in the denture-mucosal interface can produce den- ture sores, and retention of prostheses may be JADA, Vol. 138 http://jada.ada.org September 2007 17S BOX Oral and pharyngeal effects of salivary hypofunction. dDental caries dDry lips dDry mouth dDysgeusia dDysphagia dGingivitis dHalitosis dMastication problems dMucositis dOropharyngeal candidiasis dPoorly fitting prostheses dSleeping difficulty dSpeech difficulty dTraumatic oral lesions Figure 1. Plaque and calculus accumulations in a patient with severe salivary hypofunction and xerostomia. Copyright ©2007 American Dental Association. All rights reserved. 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 sub- sequent 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, ery- thema of the underlying tissues and/or a burning sensation of the tongue or other intraoral soft tis- sues (Figure 2). Fungus-associated denture stom- atitis 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. 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. 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 pos- teroinferior border of the mandible. TREATING PATIENTS WITH XEROSTOMIA The first step in treating patients with xero- stomia is establishing a diagnosis. This fre- quently involves a multidisciplinary team of health care practitioners among whom communi- cation is critical, because many older people have concomitant medical problems and polypharma- ceutical 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 top- ical fluorides and antimicrobial mouthrinses are critical to help prevent dental caries (Table 24 ). 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. 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 18S JADA, Vol. 138 http://jada.ada.org September 2007 Figure 2. Pseudomembraneous candidiasis plaques on the tongue of a patient with salivary hypofunction and xerostomia. 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. Copyright ©2007 American Dental Association. All rights reserved. secretagogues, pilo- carpine 25,26 and cevimeline, 27,28 for the treatment of xero- stomia and salivary hypofunction. These drugs are effective in increasing secretions and diminishing xerostomic complaints in patients with suffi- cient exocrine tissue. Pilocarpine is a non- selective muscarinic agonist, whereas cevimeline reportedly has a higher affinity for M1 and M3 mus- carinic receptor sub- types. Because M2 and M4 receptors are located on cardiac and lung tissues, cevime- line treatment, in theory, should enhance salivary secretions while diminishing adverse effects on pulmonary and cardiac function. Oral candidiasis is a frequent complica- tion of dry mouth and most commonly is treated with topical antifungal agents (Table). Oral rinses, ointments, pastilles and troches are effec- tive 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 con- taining 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, Scully 29 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 xero- stomia can be diminished, because salivary output is lowest at night. 8 In addition, if a patient JADA, Vol. 138 http://jada.ada.org September 2007 19S TABLE Treatment of xerostomia-associated problems.* XEROSTOMIA-ASSOCIATED PROBLEM TREATMENT STRATEGY * Source: Ship. 24 Dental Caries Dry Mouth Dysgeusia Dysphagia Oral Candidiasis Bacterial Infections Poorly Fitting Prostheses dDaily use of fluoridated dentifrice (0.05 percent sodium fluoride) dDaily use of prescription fluoride gel (1.0 percent sodium fluoride, 0.4 percent stannous fluoride) dApplication of 0.5 percent sodium fluoride varnish to teeth dDental examinations at least every six months and bitewing radiographs every 12 months for early diagnosis dOral moisturizers/lubricants, mouthwashes and sprays dSugar-free gums, mints, lozenges dArtificial salivary replacements dPrescription sialogogues: pilocarpine (5 milligrams three times per day and at bedtime); cevimeline (30 mg three times per day) dLubricants on lips every two hours dUse of bedside humidifier during sleeping hours dDrinking of fluids while eating dCareful eating, with fluids dCopious use of fluids during meals dAvoidance of dry, hard, sticky and difficult-to- masticate foods dAntifungal rinses: nystatin oral suspension (100,000 units/milliliter), rinse four times per day dAntifungal ointments: nystatin ointment applied four times per day dAntifungal lozenges dissolved in mouth four times per day, nystatin pastilles (200,000 units), clotrimazole troches (10 mg), nystatin vaginal suppositories dDenture antifungal treatment (daily hygiene): soak prosthesis for 30 minutes in benzoic acid, 0.12 percent chlorhexidine or 1 percent sodium hypochlorite dSystemic antibiotic therapy for 10 days: amoxicillin with clavulanate (500 mg every eight hours); clindamycin (300 mg three times per day); cephalexin (500 mg every six hours) dIncrease in hydration dSalivary stimulation with sugar-free gums, mints, lozenges dSoft- and hard-tissue relines by dentist dUse of denture adhesives Copyright ©2007 American Dental Association. All rights reserved. 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 Complaints of a dry mouth (xerostomia) and diminished salivary output (salivary hypofunc- tion) 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 interven- tional treatments to reduce the impact of these disorders on an older person’s quality of life. ■ 1. Ship JA, Pillemer SR, Baum BJ. Xerostomia and the geriatric patient. J Am Geriatr Soc 2002;50(3):535-43. 2. Fox PC. Autoimmune diseases and Sjögren’s syndrome: an autoim- mune exocrinopathy. Ann N Y Acad Sci 2007;1098:15-21. 3. Shiboski CH, Hodgson TA, Ship JA, Schiodt M. Management of salivary hypofunction during and after radiotherapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(supplement 1):S66-S73. 4. Bergdahl M. Salivary flow and oral complaints in adult dental patients. Community Dent Oral Epidemiol 2000;28(1):59-66. 5. von Bultzingslowen I, Sollecito TP, Fox PC, et al. Salivary dysfunc- tion associated with systemic diseases: systematic review and clinical management recommendations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(supplement 1):S57-S65. 6. Ghezzi EM, Wagner-Lange LA, Schork MA, et al. Longitudinal influence of age, menopause, hormone replacement therapy, and other medications on parotid flow rates in healthy women. J Gerontol A Biol Sci Med Sci 2000;55(1):M34-M42. 7. Ghezzi EM, Ship JA. Aging and secretory reserve capacity of major salivary glands. J Dent Res 2003;82(10):844-8. 8. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth: 2nd edition. Gerodontology 1997;14(1):33-47. 9. Närhi TO. Prevalence of subjective feelings of dry mouth in the elderly. J Dent Res 1994;73(1):20-5. 10. Thomson WM, Chalmers JM, Spencer AJ, Slade GD. Medication and dry mouth: findings from a cohort study of older people. J Public Health Dent 2000;60(1):12-20. 11. Epstein JB, Tsang AH, Warkentin D, Ship JA. The role of salivary function in modulating chemotherapy-induced oropharyngeal mucositis: a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94(1):39-44. 12. Meurman JH, Laine P, Lindqvist C, Teerenhovi L, Pyrhonen S. Five-year follow-up study of saliva, mutans streptococci, lactobacilli and yeast counts in lymphoma patients. Oral Oncol 1997;33(6):439-43. 13. Allweiss P, Braunstein GD, Katz A, Waxman A. Sialadenitis fol- lowing I-131 therapy for thyroid carcinoma: concise communication. J Nucl Med 1984;25(7):755-8. 14. Eisbruch A, Ten Haken RK, Kim HM, Marsh LH, Ship JA. Dose, volume, and function relationships in parotid salivary glands following conformal and intensity-modulated irradiation of head and neck cancer. Int J Radiat Oncol Biol Phys 1999;45(3):577-87. 15. Vitali C, Bombardieri S, Jonsson R; European Study Group on Classification Criteria for Sjögren’s Syndrome, et al. Classification cri- teria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002;61(6):554-8. 16. Pillemer SR, Matteson EL, Jacobsson LT, et al. Incidence of physician-diagnosed primary Sjögren syndrome in residents of Olmsted County, Minnesota. Mayo Clinic Proc 2001;76(6):593-9. 17. Fox RI, Stern M, Michelson P. Update in Sjögren syndrome. Curr Opin Rheumatol 2000;12(5):391-8. 18. Kassan SS, Thomas TL, Moutsopoulos HM, et al. Increased risk of lymphoma in sicca syndrome. Ann Intern Med 1978;89(6):888-92. 19. Bell M, Askari A, Bookman A, et al. Sjögren’s syndrome: a critical review of clinical management [published correction appears in J Rheumatol 1999;26(12):2718]. J Rheumatol 1999;26(9):2051-61. 20. Spielman AI, Ship JA. Taste and smell. In: Miles TS, Nauntofte B, Svensson P, eds. Clinical oral physiology. Copenhagen, Denmark: Quintessence; 2004:53-70. 21. Loesche WJ, Bromberg J, Terpenning MS, et al. Xerostomia, xero- genic medications and food avoidances in selected geriatric groups. J Am Geriatr Soc 1995;43(4):401-7. 22. Atkinson JC, Wu A. Salivary gland dysfunction: causes, symp- toms, treatment. JADA 1994;125(4):409-16. 23. Fox PC. Management of dry mouth. Dent Clin North Am 1997;41(4):863-76. 24. Ship JA. Diagnosing, managing, and preventing salivary gland disorders. Oral Dis 2002;8(2):77-89. 25. Johnson JT, Ferretti GA, Nethery WJ, et al. Oral pilocarpine for post-irradiation xerostomia in patients with head and neck cancer. N Engl J Med 1993;329(6):390-5. 26. Vivino FB, Al-Hashimi I, Khan Z, et al. Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjögren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group. Arch Intern Med 1999;159(2):174-81. 27. Petrone D, Condemi JJ, Fife R, Gluck O, Cohen S, Dalgin P. A double-blind, randomized, placebo-controlled study of cevimeline in Sjögren’s syndrome patients with xerostomia and keratoconjunctivitis sicca. Arthritis Rheum 2002;46(3):748-54. 28. Fife RS, Chase WF, Dore RK, et al. Cevimeline for the treatment of xerostomia in patients with Sjögren syndrome: a randomized trial. Arch Intern Med 2002;162(11):1293-300. 29. Scully C. Drug effects on salivary glands: dry mouth. Oral Dis 2003;9(4):165-76. 20S JADA, Vol. 138 http://jada.ada.org September 2007 Copyright ©2007 American Dental Association. All rights reserved. . salivary secretions while diminishing adverse effects on pulmonary and cardiac function. Oral candidiasis is a frequent complica- tion of dry mouth and most commonly. OF XEROSTOMIA AND SALIVARY HYPOFUNCTION Saliva is essential for the preservation of oropha- ryngeal health, and it serves many functions in the oral and