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

Dry mouth salivary hypofunction, xerostomia is a common problem among older people.. Complaints of a dry mouth xerostomia and diminished salivary output are common in older populations,

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.

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

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

A B S T R A C T

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.

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Dry mouth and its effects on the oral health

of elderly people

Michael D Turner, DDS, MD; Jonathan A Ship, DMD, FDS RCS (Edin)

that have been conducted; however, Ship and

col-leagues1estimated 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,2and 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.4,5Interestingly, output from the major

sali-vary glands does not undergo clinically significant

decrements in healthy older people.6Some 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.1-3,5Furthermore, evidence suggests

that salivary glands are vulnerable to the

delete-rious effects of all of these conditions in elderly

people,7which 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 Schwartz8reported 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.11After completing therapy, most patients experience a return of

sali-vary function to prechemotherapy levels; however, long-term changes

in salivary function have been reported.12Radioactive 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.3Radiation-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.14Most 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

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.

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,16with

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 hypofuncdiges-tion 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

BOX Oral and pharyngeal effects

of salivary hypofunction.

d Dental caries

d Dry lips

d Dry mouth

d Dysgeusia

d Dysphagia

d Gingivitis

d Halitosis

d Mastication problems

d Mucositis

d Oropharyngeal candidiasis

d Poorly fitting prostheses

d Sleeping difficulty

d Speech difficulty

d Traumatic oral lesions

Figure 1 Plaque and calculus accumulations in a patient with

severe salivary hypofunction and xerostomia.

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.22,23A low-sugar diet and daily use of top-ical 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

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

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.

secretagogues,

pilo-carpine25,26and

cevimeline,27,28for 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, Scully29reported 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.8In addition, if a patient

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

d Daily use of fluoridated dentifrice (0.05 percent sodium fluoride)

d Daily use of prescription fluoride gel (1.0 percent sodium fluoride, 0.4 percent stannous fluoride)

d Application of 0.5 percent sodium fluoride varnish

to teeth

d Dental examinations at least every six months and bitewing radiographs every 12 months for early diagnosis

d Oral moisturizers/lubricants, mouthwashes and sprays

d Sugar-free gums, mints, lozenges

d Artificial salivary replacements

d Prescription sialogogues: pilocarpine (5 milligrams three times per day and at bedtime); cevimeline (30 mg three times per day)

d Lubricants on lips every two hours

d Use of bedside humidifier during sleeping hours

d Drinking of fluids while eating

d Careful eating, with fluids

d Copious use of fluids during meals

d Avoidance of dry, hard, sticky and difficult-to-masticate foods

d Antifungal rinses: nystatin oral suspension (100,000 units/milliliter), rinse four times per day

d Antifungal ointments: nystatin ointment applied four times per day

d Antifungal lozenges dissolved in mouth four times per day, nystatin pastilles (200,000 units), clotrimazole troches (10 mg), nystatin vaginal suppositories

d Denture antifungal treatment (daily hygiene): soak prosthesis for 30 minutes in benzoic acid,

0.12 percent chlorhexidine or 1 percent sodium hypochlorite

d Systemic 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)

d Increase in hydration

d Salivary stimulation with sugar-free gums, mints, lozenges

d Soft- and hard-tissue relines by dentist

d Use of denture adhesives

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 ■

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3 Shiboski CH, Hodgson TA, Ship JA, Schiodt M Management of

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