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What You May (and May Not) Know About Dry Mouth in Your Patients
By Melissa Tennen
We’ve all experienced dry mouth at some point in our lives, such as feeling nervous before a presentation or anxious about a trip. For most people, it goes away.
But for 10% of the US population,1 dry mouth is a chronic issue, which the dental team cannot overlook. Dry mouth, also known as xerostomia, can have significant implications in oral health, if left unchecked.
Xerostomia is not a disease but rather a symptom or side effect. Whether an adverse effect of a medication or a sign of disease, xerostomia can cause discomfort in patients and affect their oral health. For the long term, xerostomia could mean an increased risk for plaque, tooth demineralization, dental caries, dental erosion, oral yeast infections, and ulcers of the tongue.2 The problem is more common in the elderly; almost 25% of people ages 65 years and older are affected.1 As patients age, they are more likely to have more conditions such as diabetes mellitus that need pharmacologic treatment.1 Many patients may be taking more than one medication—known as polypharmacy.
The Mouth’s Mineral Bath
Saliva allows food to be tasted and easily swallowed.1 Also, without enough moisture, speech may be hindered.3
The average person will produce between 0.5 to 1.5 liters of saliva every 24 hours.4 Water makes up 99% of saliva, and the rest of saliva is comprised of electrolytes, such as potassium and bicarbonate ions, mucus, enzymes (lysozyme), and antibacterial agents. These components are important for oral health, particularly in helping to prevent caries.1
Here is a closer look1:
• Electrolytes: remineralize tooth enamel as well as help modulate taste sensitivity and control pH.
• Mucus: lubricates to help with swallowing and coats the mouth to prevent food from directly contacting the epithelial cells in the mouth and esophagus.
• Enzymes: kill bacteria and prevent the overgrowth of oral microbial populations while aiding in digestion by breaking down starch.
• Antibacterial agents: act as a part of the immune system, including defensins that help prevent caries.
In xerostomia, an impaired salivary gland produces less saliva2; usually the problem is associated with inadequate functioning of the parotid, sublingual, and submandibular salivary glands,1 which are all part of the salivary gland system. Each gland produces a unique product. The parotid glands are in each cheek in front of the ears, the sublingual glands are beneath the tongue on the floor of the mouth, and the submandibular glands in the neck are near the lower edge of each side of the mandible. Eating or smelling food will stimulate this system—the parasympathetic and sympathetic nerves, which control the release of fluids. By the same token, stress and anxiety may inhibit this system.1
Dry mouth is caused by various salivary and nonsalivary sources, making it important that the cause is determined.3 Medications are the most common causes of xerostomia. Among the more than 500 medications3 known to cause this problem are antihistamines, antihypertensives, antidepressants, painkillers, decongestants, and diuretics.5 The risk for xerostomia increases with the number of medications taken.3 In addition, xerostomia is also a sign or symptom of diseases and conditions, which include Sjögren’s syndrome, endocrine disorders, diabetes mellitus, Alzheimer’s disease, Parkinson’s disease, AIDS, anxiety disorders, and stroke.5
Radiation for head and neck cancer can also cause xerostomia because the treatment can damage the salivary glands.5 Also, salivary gland traumas and tumors along with nutritional deficiencies, including eating disorders, can all lead to salivary causes of oral dryness.3
Hormonal changes, such as those that occur during pregnancy or menopause, could be another cause. Snoring and breathing open mouthed can also be factors.6
Clinically, a patient will have dry lips and irritation at the corners of the mouth. The buccal mucosa will be dry, often sticking to a mirror or retraction device. The tongue will be dry and cracked and have a little papillation. It’s common to see plaque accumulation, cervical caries, and many previously restored teeth.3
Common symptoms of xerostomia may include:
• A sticky or burning feeling in the mouth or throat3
• Cracked lips3
• Rough tongue3
• Trouble chewing, swallowing, tasting, or speaking3
• Mouth sores3
• Infection in the mouth7
Thrush, or candidiasis, may occur when saliva decreases. Patients who have thrush may have white, cottage cheese-like plaque and reddened tongue.1
Patients wearing dentures who have xerostomia may find their prosthetics uncomfortable because the thin film of saliva is not there to help the dentures stick. Xerostomia in these patients can lead to painful denture sores, dry and cracked lips, and increased risks for oral infection.5 Also, xerostomia can contribute to halitosis.
Dry Mouth Management and Treatment
Xerostomia can be managed effectively in several ways. Urge patients to visit the office regularly, and ask them to bring a list of their medications for every visit. Physicians change dosages and add or subtract medications from a patient’s regimen. So getting a list at every visit can provide a vital piece of the puzzle when assessing a patient’s oral health.
Taking a medical history is useful because some patients may be unaware they have saliva reductions until signs of xerostomia appear, such as caries and soreness.1
Discourage patients from using hard candies, sugary drinks, and sugar-containing gum because this can add to the risk for caries. Also, drinking caffeinated and acidic products should be discouraged. Sugarless gum and xylitol products may be better choices.
Sometimes if xerostomia is caused by medication, a different medication or dosage may help relieve the side effect. Patients should be urged to talk with their physicians and pharmacists about their medications.
Empower patients with education (Table 1). Explain to them what the condition is, what causes it, and how it can be managed or addressed. Remember, an educated patient makes for a healthier patient. Please see the What’s Online section for a patient resource that you can share.
Xerostomia can be mitigated with the use of some useful products, such as oral rinses or artificial saliva. Table 2 outlines a few products available. The Food and Drug Administration regulates artificial saliva products as medical devices. They work by moistening and lubricating the mouth but do not stimulate the salivary glands to make saliva. They can provide temporary relief of xerostomia. They are available as rinses, sprays, swabs, gels, and tablets. Some are prescription and some are over-the-counter.
Saliva plays an important role in sustaining oral health—and you do too. By being diligent, educating patients about their issue, and being proactive, you can be an important influence in helping patients have oral health for life.
1. Malcmacher L. Xerostomia and the critical role of saliva. Inside Dentistry Web site. http://www.dentalaegis.com/id/2007/03/focus-on-xerostomia-and-the-critical-role-of-saliva. Accessed March 9, 2013.
2. Xerostomia. The prevalent dry mouth syndrome. Inside Dental Assisting Web site. http://www.dentalaegis.com/ida/2011/06/xerostomia-the-prevalent-dry-mouth-syndrome. Accessed March 9, 2013.
3. Ciarrocca K, Hupp WS, Firriolo FJ, De Rossi SS. Dry mouth: diagnosis and management. Inside Dental Assisting Web site. http://www.cdeworld.com/courses/4540. Accessed March 9, 2013.
4. Taybos GM. The management of xerostomia. Inside Dentistry Web site. http://www.dentalaegis.com/id/2009/06/periodontics-the-management-of-xerostomia. Accessed March 9, 2013.
5. American Dental Association. Dentists, pharmacists raise awareness of medication-induced dry mouth [press release]. August 11, 2011. http://www.ada.org/6114. Accessed March 9, 2013.
6. US Food and Drug Administration Web site. For consumers. Dry mouth? Don’t delay treatment. www.fda.gov/For Consumers/ConsumerUpdates/ucm254273.htm. Accessed March 9, 2013.
7. Patient guide. Dry mouth. Aegis Communications Web site. http://www.dentalaegis.com/resources/Patient_Guide_Dry_Mouth.pdf. March 9, 2013.