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Xerostomia: Diagnosis and treatment planning considerations
Xerostomia: Diagnosis and treatment planning considerations Birgit Junjin Glass, D.D.S., M.S..* Margot L. Van Dis, D.D.S.,** Robert P. Langlais, D.D.S., iU.S.,*** and Dale A. Miles, D.D.S.,**** San Antonio, Texas, and Halifax, Nova Scotia, Canada UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO AND DALHOUSIE UNIVERSITY Long-term xerostomia results in a poor prognosis for the remaining dentition, existing restorations, and denture acceptance. The dentist must be able to recognize xerostomia by the clinical signs and the potential for xerostomia on the basis of a medical history, since xerostomia may not always be the patient’s chief complaint. A literature review concerning the etiology, diagnosis, and management of xerostomia (ORAL
SURC.
is presented. 58:248-252,
1984)
X erostomia refers to a subjective clinical condition of a less than normal amount of saliva without defining a boundary between normal and abnormal. Etiologically, xerostomia can be divided into three broad categories: radiation-induced, pharmacologically induced, and that associated with systemic conditions unrelated to radiation or pharmaceuticals. A patient may complain only of a feeling of dryness which interferes with speaking and eating and not be aware that the condition is contributing to other oral problems, such as dental caries. Therefore, xerostomia must be viewed as a critical factor in overall treatment planning rather than merely a condition to be treated in response to the complaint. There are several problems in the clinical evaluation of xerostomia. One of these is that there is no simple, quantitative method for determining whether xerostomia is clinically present. Ben-Aryeh and associates’ found that patients suffering from xerostomia had elevated salivary IgA levels and that patients who were diagnosed as having keratoconjunctivitis sicca and rheumatoid arthritis in addition to xeros*Assistant Professor, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio Dental School. **Postdoctoral Student, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio Dental School. ***Professor and Head of the Graduate Division, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio Dental School. ****Assistant Professor, Division of Oral Diagnosis/Radiology, Dalhousie University.
248
tomia (Sjiigren’s syndrome) showed elevated sodium and potassium concentrations as well as elevated IgA concentrations in whole, unstimulated saliva. However, such sialochemistry is not available to all practitioners. Second, a patient is not always aware of a diminished salivary flow. Recognition, then, must come from the knowledge of an informed practitioner as to causative factors, as well as clinical signs and symptoms which should alert the practitioner despite a negative history. The overall treatment plan for the patient should include a consideration of the potential destruction caused by xerostomia and whether or not this condition can be controlled. ETIOLOGY Radiation-induced
xerostomia
Ionizing radiation to the head and neck for treatment of cancer results in pronounced changes in salivary glands located within the primary beam. The changes involve degeneration of the acini, resulting in their replacement by fibrous or fatty tissue.2 The extent of the degenerative changes depends upon the amount of radiation used. Quantitative salivary gland scintigraphy has become a standard method for functional exploration of salivary gland diseases. In this technique, gamma rays are emitted from an isotope, 99mTc-pertechnetate. The varying concentrations of isotope taken up by the gland serve as measures of gland function. Results of this technique have shown that radiation doses from 4,000 to 6,000 rads (radiation absorbed dose), resulted in reduced
Xerostomia
Volume 58 Number 2
uptake of isotope due to the destruction and fibrosis of the involved gland. In contrast, at levels of from 1,000 to 3,000 rads there was an increased uptake due to an acute inflammatory retention of saliva. The latter has a favorable prognosis and is reversible.’ Pharmacologically
induced xerostomia
249
Table I. Classes of pharmacologic agents with xerostomic side effects4 Analgesic mixtures Anticonvulsants Antiemetics Antihistamines Antihypertensives Antinauseants Antiparkinson Antipruritics Antispasmodics Appetite suppressants
Cold medications Diuretics Decongestants Expectorants Muscle relaxants Psychotropic drugs (including CNS depressants, dibenzapin derivatives, phenothiazine derivatives, MAO inhibitors, major and minor tranquilizers) Sedatives
Memorization of every pharmacologic agent which has xerostomic side effects would be a herculean task. Bahn4 listed and rated 250 drugs with xerostomic side effects, and in the ensuing 9 years large numbers of new drugs should be added to the list. More useful would be knowledge of the major classes of drugs which produce xerostomia, as shown in Table I. In one survey of 4,365 dental patients, 43.1% were taking some type of medication. Of these, 20.8% were taking medications which also have xerostomic side effects.’ It must be kept in mind that these classes of drugs include many overthe-counter drugs which the patient may fail to mention, especially the newer over-the-counter “diet pills.” Also, over-the-counter drugs may not be listed in all pharmacologic reference materials. Therefore, the clinician may have a more difficult time determining whether or not xerostomia is a side effect of a particular drug. Careful examination of the package may yield useful information. The anticholinergic effect of most of these drugs, and eventual interference with secretion, is not necessarily limited to the salivary glands. Other possible complaints due to the general secretory inhibition associated with these drugs may include itchy eyes, dry eyes, or chronic constipation. Return of salivary function after long-term use may be protracted over several months. Whether long-term therapy can lead to irreversible damage of the gland has not been determined.
have a marked diuretic effect, causing a generalized loss of fluids. Developmental abnormalities of the salivary glands, physical obstruction (sialoliths), infections, tumors, autoimmune states (Sjiigren’s syndrome), and certain diseases which affect afferent or efferent portions of the neural transmission reflex are some of the other causes.’ Additional causes that have been reported include postoperative complications surrounding gastric resection and/or vagotomy,* depression (not being treated with medication and involving anxious, agitated depressions as opposed to apathetic depression),9 dysglycemia (whether hyperglycemia or hypoglycemia),‘O stress,” primary biliary scleroderma (another “dry-gland” syndrome with features of chronic graft-versus-host disease),‘* systemic lupus erythematosis,13 and rheumatoid arthritis.14 Mouth breathing, especially in children, should not be overlooked. Aging also has been implicated in xerostomia because the complaint is so common among the elderly.15 However, there is no evidence that the aging process alone is responsible for xerostomia.‘6 It may have become a convenient “basket” for xerostomia of unknown origin.
Systemic alterations
ORAL MANIFESTATIONS
resulting In xerostomia
Xerostomia as a result of systemic alterations may vary from a transient decrease in flow, as seen in psychogenic responses, to more severe, permanent alterations, as seen in Sjogren’s syndrome. Some conditions causing xerostomia include deficiency states, such as pernicious anemia, irondeficiency anemia, and deficiencies of vitamin A and hormones; however, no studies have demonstrated a direct cause-and-effect relationship. A pilot study of patients with diabetes mellitus has shown a significant decrease in right parotid flow when compared to a group of nondiabetic patients.6 Also implicated in xerostomia are fluid losses associated with hemorrhage, sweating, diarrhea, vomiting, and diabetes insipidus. Certain diets, especially high-protein diets,
The function of saliva is to keep the oral tissues moist as an aid in chewing, swallowing, and speech. Saliva also has properties that aid in the mechanical removal of food, digestion, protection against disease, and neutralizing of acids. Therefore, even a partial lack of saliva can be cited as contributory to the signs and symptoms listed in Table II. Indirect signs of xerostomia are often very distinct. The oral mucosa is dry, smooth, and shiny in appearance, and changes in the tongue vary from slight reddening with mild fissuring to severe lobulation.’ The tissue may also have a parched appearance and can be sticky or tacky to fingers or instruments. The glands are more prone to infections, since the decrease in flow will not prevent bacteria from
250
Glass et al.
Oral Surg. August, 1984 Table
II. Signs and symptoms of xerostomia
Signs:
Symptoms:
1. This patient had had radiation to the head and neck region. Note the “amputation” caries as well as the lobulations and fissuring in the tongue.
Fig.
ascending into the gland. It has been suggested that IgA in mucous secretions may inhibit the binding of potentially pathogenic organisms to the mucous membranes and thereby prevent infection.” Candidiasis may also become more prevalent as the oral flora changes. Dental caries studied in irradiated patients shows carious lesions appearing primarily on the buccal, palatal, lingual, and incisal surfaces of all teeth. These lesions eventually surround the teeth at the cervical margins and continue until amputation of the crown occurs. Histologic studies show these carious lesions to be similar to carious lesions of other conditions,2 and xerostomic states from a variety of causes can produce similar patterns of caries (Figs. 1 and 2). In mouth breathers, xerostomia is limited primarily to the exposed anterior maxillary teeth and the caries pattern is somewhat different. Caries is limited primarily to the anterior maxillary interproximal areas. Although the causative nature of xerostomia in human dental caries is implicated primarily through correlation studies in man, experimental studies on hamsters show an increase in caries incidence when the salivary glands are removed. Furthermore, these studies have demonstrated that the volume of salivary flow is more important than the presence or absence of a particular salivary constituent in limiting tooth decay.18 TREATMENT-PLANNING
CONSIDERATIONS
Treatment-planning considerations must include management of xerostomia as well as prevention of the adverse effects produced by the long-term lack of saliva. These are summarized in Table III. One consideration is the degree of disturbance of
Rampant decay, especially circumferential cervical caries (amputation caries) Epithelial atrophy Inflammatory fissuring Inflammation with consequent infection of salivary glands Candidiasis Burning sensation Sore tongue and lips Ulcerations Difficulty with denture retention Dryness Abnormalities of taste and smell Stickiness of tongue to palate
the gland which can be evaluated by a positive response to a stimulant, such as 2% solution of citric acid swabbed on the tongue.19 Spielman and associates19 developed a mouth rinse (Saliram) containing citric acid as a stimulant. In their study, 16% of the patients treated with the mouth rinse had increased salivation which persisted after treatment was discontinued. One potential problem with this method of treatment is the erosion that will occur with prolonged use of citric acid.*OOne treatment not recommended for stimulating salivary flow is the continuous use of tart hard candy which even a physician may recommend to a patient on medication; Any sugared substance will only increase the caries rate. Mouth rinses containing alcohol are also contraindicated because of their drying at&t. If stimulation does result in an increased flow, Tully*’ suggests that patients carry toothpicks in their mouths since any foreign object will stimulate salivary flow. In addition, a patient may use the toothpick as an adjunct to the oral hygiene procedures. If there is no response to the stimulant, a saliva substitute is necessary. Shannon and colleagues** introduced a saliva substitute (VA-OraLube) for irradiated patients. This solution is designed to serve two purposes: to relieve soft-tissue discomfort and to induce rehardening of softened tooth surface.** The microhardness data presented point out that the solution does have a potential for rehardening softened enamel surfaces. In a study of patients with Sjiigren’s syndrome, the above saliva substitute was compared to a glycerine mouthwash (control). No significant difference was appreciated by patients between the two in relieving oral symptoms, except that use of the experimental saliva resulted in a reduction of nocturnal discomfort.23 However, since glycerine mouthwash has no mineralizing properties, the remineralizing solution would be of value for any
Volume Number
58 2
Table
III. Treatment
1. 2. 3. 4. 5. 6. 7.
Xerostomia
25 1
planning considerations
Saliva substitute versus saliva stimulant Reversibility of condition Alternate pharmaceuticals Reduction of medication Length of time xerostomia is expected to be present Physical ability for oral hygiene maintenance Patient motivation
dentulous patient with long- or short-term xerostomia. Weiszz4 has also shown that VA-OraLube* is effective in treating soft-tissue discomfort in Sjijgren’s syndrome, as is Sali-Synt.t25 Donatosky and co-workers26 found that Salimentt alleviated the subjective sensation of xerostomia in addition to stimulating parotid salivary secretion. Xero-Lubes is another commercially available substitute, which also contains a fluoride concentration of two parts per million. No prescription is required. Patients may be instructed to use the saliva substitutes as often as needed. Other palliative treatments include avoidance of dry, bulky, spicy, or acidic foods, alcoholic or carbonated beverages, and tobacco. In addition, maintenance of optimum air humidification may be beneficial.16 Another consideration is the reversibility of xerostomia. Physical examination of mouth breathers may reveal an operable nasal obstruction. Patients on self-medication or special diets may decide to eliminate them when made aware of the possible consequences. Consultation with a physician may result in a change to antidepressant medication without the xerostomic side effects, such as trazodone HCl.*’ Where change is not possible, concurrent use of a cholinergic medication to minimize the anticholinergic effect of tricyclic antidepressants may be coordinated with the patient’s physician. Bethanecol chloride is one such medication which has been shown not to interfere with the antidepressant effect while at the same time relieving the anticholinergic effect of the tricyclic antidepressants.28 Sialogogues, such as pilocarpine, are also prescribed to counteract anticholinergic effects of medications. One danger with the last two methods involves the taking of one more medication and the possible side effects of the combination. Consideration should be given to the *Commercially available as Orex, Ing’s Dental Specialty Fort Wayne, Ind. t.Sali-Synt, 1 Remeda Pharmaceutical Co., Finland. $Saliment, Ferring Ltd., Copenhagen, Denmark. $Xero-Lube, Scherer Laboratories, Inc., Dallas, Texas.
Co.,
2. Radiographs taken on Nov. 1, 1977 (A) and on July 13, 1978 (B). Note the typical pattern of caries due to xerostomia and the short amount of time for destruction to occur. Medications for that period of time included Inderal, Cogentin, Benadryl, Colace, and antacids.
Fig.
length of time the patient is expected to be on medication. There are still more questions than answers concerning xerostomia. How extensive must it be to produce caries? Does controlling such conditions as diabetes mellitus or lupus erythematosis result in reversal of the xerostomia? Because of these and other unanswered questions, the practitioner must take initial steps to counteract the potential side effects. Studies on irradiated patients have shown that oral hygiene measures alone are totally inadequate against prevention of dental decay. In a study by Driezen and associates,29 application of a 1% sodium fluoride gel and oral hygiene regimen were successful regardless of dietary intake. Westcott and co-workers30 showed that 0.4% stannous fluoride gel is effective in controlling the development of postirradiation dental caries if used on a daily basis in conjunction with a program of oral hygiene. It is not necessary to use a tray with the stannous fluoride gel if the patient follows the directions given with the gel. Whether applied in a tray or with a toothbrush, the teeth must be wet when stannous fluoride gel is applied to ensure that enough stannous and fluoride ions are released. These are needed to form stannous fluorophosphate, which gives the protective effect.
252
Glass et al.
The use of a fluoride gel in conjunction with an oral hygiene program would benefit any xerostomic patient; however, any rigid oral hygiene regimen requires the dexterity and vision necessary to carry it out. A physical or visual handicap would alter the prognosis of the remaining teeth and restorations. Six-month recall appointments may not be sufficient initially while the cause and rate of progression of destruction are being determined. Severe dental caries can occur as early as 3 months after irradiation.29 How this rate compares with xerostomia from other causes has not been determined. The final consideration is patient motivation. Extensive dental procedures are sure to fail in the absence of strict adherence to a prescribed home care regimen. With complete failure resulting in the need for complete dentures, motivation is paramount as denture patients with xerostomia tend to have increased denture sores, increased incidence of candidiasis, and denture-retention problems. SUMMARY
Xerostomia may occur in a variety of forms. If the practitioner is alert, history alone may indicate xerostomia when, in fact, there is a clinical appearance of moistness. Conversely, the mucosa may have the dry, parched appearance indicative of xerostomia in the absence of symptoms or history. Significance lies in the fact that long-term xerostomia results in a poor prognosis for the remaining dentition, existing or planned restorations, and denture acceptance. Prognosis can be improved, depending on the length of time the xerostomia is expected to be present and on patient motivation. REFERENCES 1. Ben-Aryeh H, Spielman A, Szargel R, Gutman D, Scharf J, Nahir M, Scharf Y: Sialochemistry for diagnosis of Sjogren’s syndrome in xerostomic patients. ORAL SURG 54: 487-490, 1981. 2. Frank RM, Herdley J, Philippe E: Acquired dental defects and salivary gland lesions after irradiation for carcinoma. J Am Dent Assoc 70: 868-883, 1965. 3. Hlsler RJ, N’Guyen VT, Ritschard J, Montandon PB: Differential diagnosis of xerostomia by quantitative salivary gland scintigraphy. Ann Otol 86: 333-339, 1977. 4. Bahn SL: Drug-related dental destruction. ORAL SURG 33: 49-54, 1972. 5. Cottone JA, Kafrawy AH: Medications and health histories: A survey of 4,365 dental patients. J Am Dent Assoc 98: 713-718, 1979. 6. Conner S, Iranpour B, Mills J: Alterations in parotid salivary flow in diabetes mellitus. ORAL SURC 30: 54-59, 1970. 7. Chisholm DM, Ferguson M, Jones J, Mason DK: Introduction to oral medicine, Philadelphia, 1978, W.B. Saunders Company, pp. 143-144. 8. Galil KA: Xerostomia, a post-operative complication of vagotomy. J Oral Med 31: 82-83, 1976.
Oral August,
Surg. 1984
9. Mathew RJ, Weinman M, Claghorn JL: Xerostomia and sialorrhea in depression. Am J Psychiatry 136: 1476-1477, 1979. IO. Cheraskin E: Dry mouth and dysglycemia (letter to the editor). JAMA 229: 523, 1974. I I. Bates JF, Adams DT: The influence of mental stress on the flow of saliva in man. Arch Oral Biol 13: 395, 1968. 12. Epstein 0, Thomas HC, Sherlock S: Primary biliary cirrhosis in a dry gland syndrome with features of chronic graft vs. host disease. Lancet 31: 1 (1879); pp. 1166-l 168, May, 1980. 13. Martin DW: Lupus erythematosus-its oral manifestations. ORAL SURG 29: 846-848, 1970. 14. Ericson S: The prevalence of hyposalivation in rheumatoid arthritis and its relation to the sialographic appearance of the parotid glands. ORAL SURG 38: 315-331, 1974. 15. Lyons DC: The dry mouth adverse reaction syndrome in the geriatric patient. J Oral Med 27: 110-l II, 1972. 16. Ettinger RL: Xerostomia-a complication of aging. Aust Dent J 26: 365371, 1981. 17. Weir DM: Immunology-an outline for students of medicine and biology, ed. 4, Edinburgh, 1977, Churchill Livingstone, p. 58. 18. Klapper CE, Volker JJ: The effect of partial impairment of salivary function on dental caries in the Syrian hamster. J Dent Res 32: 227-231, 1953. 19. Spielman A, Ben-Aryeh H, Gutman D, Szargel R, Deutsch E: Xerostomia-diagnosis and treatment. ORAL SURG 51: l44147, 1981. 20. Newbrun E: Letter to the editor, ORAL SURG 52: 262, 1981. 21. Tully TA: Drug induced xerostomia and severe dental pathology: the role of psychotropic drugs. J Hosp Dent Practice 5: 122-125, 1977. 9-l Shannon LL. LL, McCrary BR, Starche EN: A saliva substitute for use of xerostomic patient undergoing radiotherapy to the head and neck. ORAL SURG 44: 656-661, 1977. 23. Klestov AC, Latt D, Schiller G, McNamara K, Young DY, Hobbs J, Fetherston J: Treatment of xerostomia: a doubleblind trial in 108 patients with SjBgren’s syndrome. ORAL SURG 51: 594-599, 198 I. 24. Weisz AS: The use of a saliva substitute as treatment for xerostomia in Sjogren’s syndrome-a case report. ORAL SURG 52: 384-386, 1981. 25. Kaarela K, Mutru 0: Xerostomia in Sjiigren’s syndrome treated with Sali-Synt. Stand J Rheumatol 11: 39-40, 1982. 26. Donatsky 0, Johnsen T, Holmstrup P, Bertram U: Effect of Saliment on parotid salivary gland secretion and on xerostomia caused by SjBgren’s syndrome. Stand J Dent Res 90: 157-162, 1982. 27. Gershon S, Newton R: Lack of outer cholinergic side effects with a new anti-depressant-trazodone. J Clin Psychiatry 41: 100-104, 1980. 28. Everett HC: The use of bethanechol chloride with tricyclic antidepressants. Am J Psychiatry 132: 1202-1204, 1975. 29. Dreizen S, Brown LR, Daley E, Drane JB: Prevention of xerostomia-related dental caries in irradiated cancer patients. J Dent Res 56: 99-104, 1977. 30. Wescott WB, Starcke EN, Shannon IL: Chemical protection against postirradiation dental caries. ORAL SURC 40: 709-719, 1975.
Reprint requests to: Dr. Birgit Junfin Glass Department of Dental Diagnostic Science University of Texas Health Science Center San Antonio Dental School 7703 Floyd Curl Dr. San Antonio, TX 78284
at
SURC.
is presented. 58:248-252,
1984)
X erostomia refers to a subjective clinical condition of a less than normal amount of saliva without defining a boundary between normal and abnormal. Etiologically, xerostomia can be divided into three broad categories: radiation-induced, pharmacologically induced, and that associated with systemic conditions unrelated to radiation or pharmaceuticals. A patient may complain only of a feeling of dryness which interferes with speaking and eating and not be aware that the condition is contributing to other oral problems, such as dental caries. Therefore, xerostomia must be viewed as a critical factor in overall treatment planning rather than merely a condition to be treated in response to the complaint. There are several problems in the clinical evaluation of xerostomia. One of these is that there is no simple, quantitative method for determining whether xerostomia is clinically present. Ben-Aryeh and associates’ found that patients suffering from xerostomia had elevated salivary IgA levels and that patients who were diagnosed as having keratoconjunctivitis sicca and rheumatoid arthritis in addition to xeros*Assistant Professor, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio Dental School. **Postdoctoral Student, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio Dental School. ***Professor and Head of the Graduate Division, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio Dental School. ****Assistant Professor, Division of Oral Diagnosis/Radiology, Dalhousie University.
248
tomia (Sjiigren’s syndrome) showed elevated sodium and potassium concentrations as well as elevated IgA concentrations in whole, unstimulated saliva. However, such sialochemistry is not available to all practitioners. Second, a patient is not always aware of a diminished salivary flow. Recognition, then, must come from the knowledge of an informed practitioner as to causative factors, as well as clinical signs and symptoms which should alert the practitioner despite a negative history. The overall treatment plan for the patient should include a consideration of the potential destruction caused by xerostomia and whether or not this condition can be controlled. ETIOLOGY Radiation-induced
xerostomia
Ionizing radiation to the head and neck for treatment of cancer results in pronounced changes in salivary glands located within the primary beam. The changes involve degeneration of the acini, resulting in their replacement by fibrous or fatty tissue.2 The extent of the degenerative changes depends upon the amount of radiation used. Quantitative salivary gland scintigraphy has become a standard method for functional exploration of salivary gland diseases. In this technique, gamma rays are emitted from an isotope, 99mTc-pertechnetate. The varying concentrations of isotope taken up by the gland serve as measures of gland function. Results of this technique have shown that radiation doses from 4,000 to 6,000 rads (radiation absorbed dose), resulted in reduced
Xerostomia
Volume 58 Number 2
uptake of isotope due to the destruction and fibrosis of the involved gland. In contrast, at levels of from 1,000 to 3,000 rads there was an increased uptake due to an acute inflammatory retention of saliva. The latter has a favorable prognosis and is reversible.’ Pharmacologically
induced xerostomia
249
Table I. Classes of pharmacologic agents with xerostomic side effects4 Analgesic mixtures Anticonvulsants Antiemetics Antihistamines Antihypertensives Antinauseants Antiparkinson Antipruritics Antispasmodics Appetite suppressants
Cold medications Diuretics Decongestants Expectorants Muscle relaxants Psychotropic drugs (including CNS depressants, dibenzapin derivatives, phenothiazine derivatives, MAO inhibitors, major and minor tranquilizers) Sedatives
Memorization of every pharmacologic agent which has xerostomic side effects would be a herculean task. Bahn4 listed and rated 250 drugs with xerostomic side effects, and in the ensuing 9 years large numbers of new drugs should be added to the list. More useful would be knowledge of the major classes of drugs which produce xerostomia, as shown in Table I. In one survey of 4,365 dental patients, 43.1% were taking some type of medication. Of these, 20.8% were taking medications which also have xerostomic side effects.’ It must be kept in mind that these classes of drugs include many overthe-counter drugs which the patient may fail to mention, especially the newer over-the-counter “diet pills.” Also, over-the-counter drugs may not be listed in all pharmacologic reference materials. Therefore, the clinician may have a more difficult time determining whether or not xerostomia is a side effect of a particular drug. Careful examination of the package may yield useful information. The anticholinergic effect of most of these drugs, and eventual interference with secretion, is not necessarily limited to the salivary glands. Other possible complaints due to the general secretory inhibition associated with these drugs may include itchy eyes, dry eyes, or chronic constipation. Return of salivary function after long-term use may be protracted over several months. Whether long-term therapy can lead to irreversible damage of the gland has not been determined.
have a marked diuretic effect, causing a generalized loss of fluids. Developmental abnormalities of the salivary glands, physical obstruction (sialoliths), infections, tumors, autoimmune states (Sjiigren’s syndrome), and certain diseases which affect afferent or efferent portions of the neural transmission reflex are some of the other causes.’ Additional causes that have been reported include postoperative complications surrounding gastric resection and/or vagotomy,* depression (not being treated with medication and involving anxious, agitated depressions as opposed to apathetic depression),9 dysglycemia (whether hyperglycemia or hypoglycemia),‘O stress,” primary biliary scleroderma (another “dry-gland” syndrome with features of chronic graft-versus-host disease),‘* systemic lupus erythematosis,13 and rheumatoid arthritis.14 Mouth breathing, especially in children, should not be overlooked. Aging also has been implicated in xerostomia because the complaint is so common among the elderly.15 However, there is no evidence that the aging process alone is responsible for xerostomia.‘6 It may have become a convenient “basket” for xerostomia of unknown origin.
Systemic alterations
ORAL MANIFESTATIONS
resulting In xerostomia
Xerostomia as a result of systemic alterations may vary from a transient decrease in flow, as seen in psychogenic responses, to more severe, permanent alterations, as seen in Sjogren’s syndrome. Some conditions causing xerostomia include deficiency states, such as pernicious anemia, irondeficiency anemia, and deficiencies of vitamin A and hormones; however, no studies have demonstrated a direct cause-and-effect relationship. A pilot study of patients with diabetes mellitus has shown a significant decrease in right parotid flow when compared to a group of nondiabetic patients.6 Also implicated in xerostomia are fluid losses associated with hemorrhage, sweating, diarrhea, vomiting, and diabetes insipidus. Certain diets, especially high-protein diets,
The function of saliva is to keep the oral tissues moist as an aid in chewing, swallowing, and speech. Saliva also has properties that aid in the mechanical removal of food, digestion, protection against disease, and neutralizing of acids. Therefore, even a partial lack of saliva can be cited as contributory to the signs and symptoms listed in Table II. Indirect signs of xerostomia are often very distinct. The oral mucosa is dry, smooth, and shiny in appearance, and changes in the tongue vary from slight reddening with mild fissuring to severe lobulation.’ The tissue may also have a parched appearance and can be sticky or tacky to fingers or instruments. The glands are more prone to infections, since the decrease in flow will not prevent bacteria from
250
Glass et al.
Oral Surg. August, 1984 Table
II. Signs and symptoms of xerostomia
Signs:
Symptoms:
1. This patient had had radiation to the head and neck region. Note the “amputation” caries as well as the lobulations and fissuring in the tongue.
Fig.
ascending into the gland. It has been suggested that IgA in mucous secretions may inhibit the binding of potentially pathogenic organisms to the mucous membranes and thereby prevent infection.” Candidiasis may also become more prevalent as the oral flora changes. Dental caries studied in irradiated patients shows carious lesions appearing primarily on the buccal, palatal, lingual, and incisal surfaces of all teeth. These lesions eventually surround the teeth at the cervical margins and continue until amputation of the crown occurs. Histologic studies show these carious lesions to be similar to carious lesions of other conditions,2 and xerostomic states from a variety of causes can produce similar patterns of caries (Figs. 1 and 2). In mouth breathers, xerostomia is limited primarily to the exposed anterior maxillary teeth and the caries pattern is somewhat different. Caries is limited primarily to the anterior maxillary interproximal areas. Although the causative nature of xerostomia in human dental caries is implicated primarily through correlation studies in man, experimental studies on hamsters show an increase in caries incidence when the salivary glands are removed. Furthermore, these studies have demonstrated that the volume of salivary flow is more important than the presence or absence of a particular salivary constituent in limiting tooth decay.18 TREATMENT-PLANNING
CONSIDERATIONS
Treatment-planning considerations must include management of xerostomia as well as prevention of the adverse effects produced by the long-term lack of saliva. These are summarized in Table III. One consideration is the degree of disturbance of
Rampant decay, especially circumferential cervical caries (amputation caries) Epithelial atrophy Inflammatory fissuring Inflammation with consequent infection of salivary glands Candidiasis Burning sensation Sore tongue and lips Ulcerations Difficulty with denture retention Dryness Abnormalities of taste and smell Stickiness of tongue to palate
the gland which can be evaluated by a positive response to a stimulant, such as 2% solution of citric acid swabbed on the tongue.19 Spielman and associates19 developed a mouth rinse (Saliram) containing citric acid as a stimulant. In their study, 16% of the patients treated with the mouth rinse had increased salivation which persisted after treatment was discontinued. One potential problem with this method of treatment is the erosion that will occur with prolonged use of citric acid.*OOne treatment not recommended for stimulating salivary flow is the continuous use of tart hard candy which even a physician may recommend to a patient on medication; Any sugared substance will only increase the caries rate. Mouth rinses containing alcohol are also contraindicated because of their drying at&t. If stimulation does result in an increased flow, Tully*’ suggests that patients carry toothpicks in their mouths since any foreign object will stimulate salivary flow. In addition, a patient may use the toothpick as an adjunct to the oral hygiene procedures. If there is no response to the stimulant, a saliva substitute is necessary. Shannon and colleagues** introduced a saliva substitute (VA-OraLube) for irradiated patients. This solution is designed to serve two purposes: to relieve soft-tissue discomfort and to induce rehardening of softened tooth surface.** The microhardness data presented point out that the solution does have a potential for rehardening softened enamel surfaces. In a study of patients with Sjiigren’s syndrome, the above saliva substitute was compared to a glycerine mouthwash (control). No significant difference was appreciated by patients between the two in relieving oral symptoms, except that use of the experimental saliva resulted in a reduction of nocturnal discomfort.23 However, since glycerine mouthwash has no mineralizing properties, the remineralizing solution would be of value for any
Volume Number
58 2
Table
III. Treatment
1. 2. 3. 4. 5. 6. 7.
Xerostomia
25 1
planning considerations
Saliva substitute versus saliva stimulant Reversibility of condition Alternate pharmaceuticals Reduction of medication Length of time xerostomia is expected to be present Physical ability for oral hygiene maintenance Patient motivation
dentulous patient with long- or short-term xerostomia. Weiszz4 has also shown that VA-OraLube* is effective in treating soft-tissue discomfort in Sjijgren’s syndrome, as is Sali-Synt.t25 Donatosky and co-workers26 found that Salimentt alleviated the subjective sensation of xerostomia in addition to stimulating parotid salivary secretion. Xero-Lubes is another commercially available substitute, which also contains a fluoride concentration of two parts per million. No prescription is required. Patients may be instructed to use the saliva substitutes as often as needed. Other palliative treatments include avoidance of dry, bulky, spicy, or acidic foods, alcoholic or carbonated beverages, and tobacco. In addition, maintenance of optimum air humidification may be beneficial.16 Another consideration is the reversibility of xerostomia. Physical examination of mouth breathers may reveal an operable nasal obstruction. Patients on self-medication or special diets may decide to eliminate them when made aware of the possible consequences. Consultation with a physician may result in a change to antidepressant medication without the xerostomic side effects, such as trazodone HCl.*’ Where change is not possible, concurrent use of a cholinergic medication to minimize the anticholinergic effect of tricyclic antidepressants may be coordinated with the patient’s physician. Bethanecol chloride is one such medication which has been shown not to interfere with the antidepressant effect while at the same time relieving the anticholinergic effect of the tricyclic antidepressants.28 Sialogogues, such as pilocarpine, are also prescribed to counteract anticholinergic effects of medications. One danger with the last two methods involves the taking of one more medication and the possible side effects of the combination. Consideration should be given to the *Commercially available as Orex, Ing’s Dental Specialty Fort Wayne, Ind. t.Sali-Synt, 1 Remeda Pharmaceutical Co., Finland. $Saliment, Ferring Ltd., Copenhagen, Denmark. $Xero-Lube, Scherer Laboratories, Inc., Dallas, Texas.
Co.,
2. Radiographs taken on Nov. 1, 1977 (A) and on July 13, 1978 (B). Note the typical pattern of caries due to xerostomia and the short amount of time for destruction to occur. Medications for that period of time included Inderal, Cogentin, Benadryl, Colace, and antacids.
Fig.
length of time the patient is expected to be on medication. There are still more questions than answers concerning xerostomia. How extensive must it be to produce caries? Does controlling such conditions as diabetes mellitus or lupus erythematosis result in reversal of the xerostomia? Because of these and other unanswered questions, the practitioner must take initial steps to counteract the potential side effects. Studies on irradiated patients have shown that oral hygiene measures alone are totally inadequate against prevention of dental decay. In a study by Driezen and associates,29 application of a 1% sodium fluoride gel and oral hygiene regimen were successful regardless of dietary intake. Westcott and co-workers30 showed that 0.4% stannous fluoride gel is effective in controlling the development of postirradiation dental caries if used on a daily basis in conjunction with a program of oral hygiene. It is not necessary to use a tray with the stannous fluoride gel if the patient follows the directions given with the gel. Whether applied in a tray or with a toothbrush, the teeth must be wet when stannous fluoride gel is applied to ensure that enough stannous and fluoride ions are released. These are needed to form stannous fluorophosphate, which gives the protective effect.
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The use of a fluoride gel in conjunction with an oral hygiene program would benefit any xerostomic patient; however, any rigid oral hygiene regimen requires the dexterity and vision necessary to carry it out. A physical or visual handicap would alter the prognosis of the remaining teeth and restorations. Six-month recall appointments may not be sufficient initially while the cause and rate of progression of destruction are being determined. Severe dental caries can occur as early as 3 months after irradiation.29 How this rate compares with xerostomia from other causes has not been determined. The final consideration is patient motivation. Extensive dental procedures are sure to fail in the absence of strict adherence to a prescribed home care regimen. With complete failure resulting in the need for complete dentures, motivation is paramount as denture patients with xerostomia tend to have increased denture sores, increased incidence of candidiasis, and denture-retention problems. SUMMARY
Xerostomia may occur in a variety of forms. If the practitioner is alert, history alone may indicate xerostomia when, in fact, there is a clinical appearance of moistness. Conversely, the mucosa may have the dry, parched appearance indicative of xerostomia in the absence of symptoms or history. Significance lies in the fact that long-term xerostomia results in a poor prognosis for the remaining dentition, existing or planned restorations, and denture acceptance. Prognosis can be improved, depending on the length of time the xerostomia is expected to be present and on patient motivation. REFERENCES 1. Ben-Aryeh H, Spielman A, Szargel R, Gutman D, Scharf J, Nahir M, Scharf Y: Sialochemistry for diagnosis of Sjogren’s syndrome in xerostomic patients. ORAL SURG 54: 487-490, 1981. 2. Frank RM, Herdley J, Philippe E: Acquired dental defects and salivary gland lesions after irradiation for carcinoma. J Am Dent Assoc 70: 868-883, 1965. 3. Hlsler RJ, N’Guyen VT, Ritschard J, Montandon PB: Differential diagnosis of xerostomia by quantitative salivary gland scintigraphy. Ann Otol 86: 333-339, 1977. 4. Bahn SL: Drug-related dental destruction. ORAL SURG 33: 49-54, 1972. 5. Cottone JA, Kafrawy AH: Medications and health histories: A survey of 4,365 dental patients. J Am Dent Assoc 98: 713-718, 1979. 6. Conner S, Iranpour B, Mills J: Alterations in parotid salivary flow in diabetes mellitus. ORAL SURC 30: 54-59, 1970. 7. Chisholm DM, Ferguson M, Jones J, Mason DK: Introduction to oral medicine, Philadelphia, 1978, W.B. Saunders Company, pp. 143-144. 8. Galil KA: Xerostomia, a post-operative complication of vagotomy. J Oral Med 31: 82-83, 1976.
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9. Mathew RJ, Weinman M, Claghorn JL: Xerostomia and sialorrhea in depression. Am J Psychiatry 136: 1476-1477, 1979. IO. Cheraskin E: Dry mouth and dysglycemia (letter to the editor). JAMA 229: 523, 1974. I I. Bates JF, Adams DT: The influence of mental stress on the flow of saliva in man. Arch Oral Biol 13: 395, 1968. 12. Epstein 0, Thomas HC, Sherlock S: Primary biliary cirrhosis in a dry gland syndrome with features of chronic graft vs. host disease. Lancet 31: 1 (1879); pp. 1166-l 168, May, 1980. 13. Martin DW: Lupus erythematosus-its oral manifestations. ORAL SURG 29: 846-848, 1970. 14. Ericson S: The prevalence of hyposalivation in rheumatoid arthritis and its relation to the sialographic appearance of the parotid glands. ORAL SURG 38: 315-331, 1974. 15. Lyons DC: The dry mouth adverse reaction syndrome in the geriatric patient. J Oral Med 27: 110-l II, 1972. 16. Ettinger RL: Xerostomia-a complication of aging. Aust Dent J 26: 365371, 1981. 17. Weir DM: Immunology-an outline for students of medicine and biology, ed. 4, Edinburgh, 1977, Churchill Livingstone, p. 58. 18. Klapper CE, Volker JJ: The effect of partial impairment of salivary function on dental caries in the Syrian hamster. J Dent Res 32: 227-231, 1953. 19. Spielman A, Ben-Aryeh H, Gutman D, Szargel R, Deutsch E: Xerostomia-diagnosis and treatment. ORAL SURG 51: l44147, 1981. 20. Newbrun E: Letter to the editor, ORAL SURG 52: 262, 1981. 21. Tully TA: Drug induced xerostomia and severe dental pathology: the role of psychotropic drugs. J Hosp Dent Practice 5: 122-125, 1977. 9-l Shannon LL. LL, McCrary BR, Starche EN: A saliva substitute for use of xerostomic patient undergoing radiotherapy to the head and neck. ORAL SURG 44: 656-661, 1977. 23. Klestov AC, Latt D, Schiller G, McNamara K, Young DY, Hobbs J, Fetherston J: Treatment of xerostomia: a doubleblind trial in 108 patients with SjBgren’s syndrome. ORAL SURG 51: 594-599, 198 I. 24. Weisz AS: The use of a saliva substitute as treatment for xerostomia in Sjogren’s syndrome-a case report. ORAL SURG 52: 384-386, 1981. 25. Kaarela K, Mutru 0: Xerostomia in Sjiigren’s syndrome treated with Sali-Synt. Stand J Rheumatol 11: 39-40, 1982. 26. Donatsky 0, Johnsen T, Holmstrup P, Bertram U: Effect of Saliment on parotid salivary gland secretion and on xerostomia caused by SjBgren’s syndrome. Stand J Dent Res 90: 157-162, 1982. 27. Gershon S, Newton R: Lack of outer cholinergic side effects with a new anti-depressant-trazodone. J Clin Psychiatry 41: 100-104, 1980. 28. Everett HC: The use of bethanechol chloride with tricyclic antidepressants. Am J Psychiatry 132: 1202-1204, 1975. 29. Dreizen S, Brown LR, Daley E, Drane JB: Prevention of xerostomia-related dental caries in irradiated cancer patients. J Dent Res 56: 99-104, 1977. 30. Wescott WB, Starcke EN, Shannon IL: Chemical protection against postirradiation dental caries. ORAL SURC 40: 709-719, 1975.
Reprint requests to: Dr. Birgit Junfin Glass Department of Dental Diagnostic Science University of Texas Health Science Center San Antonio Dental School 7703 Floyd Curl Dr. San Antonio, TX 78284
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