XEROSTOMIA

DEFINITION Refers to a subject sensation of a dry mouth. Frequently associated with salivary gland hypofunction. A common problem in 25% older adults.

CLINICAL FEATURES  in salivary secretion Residual saliva appear foamy or thick and “ropey” Examining gloves stick to the oral mucosa Dorsal tongue often is fissured with atrophy of the filiform papillae Patient may c/o difficulty in mastication and swallowing and may indicate that food adheres to the oral membranes during eating. Signs: more prone to dental decay especially at cervical and root caries. Associated more often with radiotherapy aka radiation-induction therapy.

CAUSES Salivary gland aplasia Impaired fluid intake Hemorrhage Aetiology Developmental origin Iatrogenic origin Systemic diseases Local factors Water/metabolite loss Impaired fluid intake Hemorrhage Vomiting /diarrhea Medication Radiation therapy to head and neck Chemotherapy Sjogren syndrome Diabetes mellitus Diabetes insipidus Sarcoidosis HIV Hep C infection Graft-versus-host-disease Psychogenic disorders  mastication Smoking Mouth breathing

MEDICATIONS THAT MAY PRODUCE XEROSTOMIA Class of drug Example Antihistamine agents Diphenhydramine Chlorpheniramine Sedatives and anxiolytic agents Diazepam Lorazepam Alprazolam Decongestant Pseudihepdrine Anticholinergic agents Atropine Scopolamine Antidepressant agents Amitriptyline Citalopram Fluoxetine Paroxetine Sertraline Bupropion Antihypertensive agents Resepine Methyldopa Chlorothiazide Furosemide Metoprolol Calcium channel blockers Antipsychotic agents Phenothiazine derivatives Haloperidol

EVALUATION History of present illness acuity of onset, temporal patterns (eg, constant vs intermittent, presence only on awakening) provoking factors, including situational or psychogenic factors (eg, whether xerostomia occurs only during periods of psychologic stress or certain activities) assessment of fluid status (eg, fluid intake habits, recurrent vomiting or diarrhea) sleeping habits Use of recreational drugs should be specifically elicited.

Review of systems Seek symptoms of causative disorders, including dry eyes, dry skin, rashes, and joint pain (Sjögren's syndrome) Past medical history conditions associated with xerostomia, including Sjögren's syndrome history of radiation treatment, head and neck trauma, and a diagnosis of or risk factors for HIV infection Drug profiles should be reviewed for potential offending drugs

Physical examination oral cavity, the condition of the teeth unusual caries site. specifically any apparent dryness (eg, whether the mucosa is dry, sticky, or moist; whether saliva is foamy, thick, stringy, or normal in appearance) presence of any lesions caused by Candida albicans areas of erythema and atrophy Less common is the better-known white, cheesy curd that bleeds when wiped off. Tongue depressor Place on buccal mucosa for 10 sec. If the tongue blade falls off immediately when released, salivary flow is considered normal Lipstick Sign Lipstick adhere to front teeth Useful indicator Palpation  submandibular, sublingual, and parotid glands. Drying the duct openings with a gauze square before palpation aids observation Container Expectorate once to empty mouth. Then expectorate all saliva into container Normal production is 0.3 to 0.4 mL/min. Significant xerostomia is 0.1 mL/min.

Interpretation of findings Xerostomia is diagnosed by symptoms, appearance, and absence of salivary flow when massaging the salivary glands.   Xerostomia d/t drugs No further assessment Xerostomia after H&N radiation Xerostomia after H&N trauma abrupt onset May be caused by nerve damage Concomitant presence of dry eyes,dry skin, rash or joint pain Suggestive of sjogren syndrome Severe tooth decay, findings out of proportion May indicate drug abuse (methamphetamines) Only during night time or on awakening Excessive mouth breathing in dry environment

Other test Sialometry: salivary flow measurement Should the presence of xerostomia become unclear: Sialometry: salivary flow measurement collection devices are placed over salivary gland orifices saliva is stimulated with citric acid Sialogaphy: imaging technique in identifying stones and masses injection of radio-opaque media into the salivary glands Salivary scintigraphy To assess salivary gland function Biopsy Minor salivary gland To dx Sjogren Syndrome, HIV-related salivary gl ds, sarcoidosis, amyloidosis and graft-vs- host disease Biopsy Major salivary gland Malignancy suspected

Management of Xerostomia Identify the underlying cause Provide symptomatic treatment where little can be done to alter the underlying cause It Aims are: Increase existing saliva flow Replacing lost secretion Control dental caries Control specific measure i.e. infection

Treatment Drug-related xerostomia: cannot changed to another drug. Schedule to optimize drug effect during the day Custom-fitted acrylic night guards carrying fluoride gel. Drugs in liquid should be considered than sublingual osage. Lubricate mouth and throat with water before swallowing cap. Tab. Or b4 sublingual nitroglycerin Avoid decongestant and antihistamine

Symptomatic treatment drugs that  saliva production: Cevimeline (30 mg po tid) An cholinergic agonists SE: nausea Pilocarpine (5 mg po tid) SE: sweating, flushing, polyuria Other ways to increase saliva secretion Chewing xylitol-containg gum Sipping sugarless fluid OTC saliva substitue containing carboxymethylcellulose, hydroxycellulose or glycerin Petroleum jelly apply to lips and under denture Cold-air humidifier my aid mouth breathers

Symptomatic treatment Control caries Brush and floss regularly; fluoride rinses or gels daily Use newer toothpaste with added ca and phosphorus may px rampant caries Individual fitted carriers containing 1.1% Na fluoride or 0.4% SnF Apply 5% Na fluoride varnish 2-4x/year

http://www. merckmanuals http://www.merckmanuals.com/professional/dental_disorders/symptoms_of_dental_and_oral_disorders/xerostomia.html http://www.oralcancerfoundation.org/complications/xerostomia.php CONTEMPORARY OPOM, NEVILLE