How do I Manage a Patient with Xerostomia/Dry Mouth?

May 16, 2016

Xerostomia is not a disease but a symptomatic sensation of mouth dryness. It is usually characterized by abnormal reduction in the rate of salivary flow. It can be an oral manifestation of particular diseases or metabolic disorders and can be a side effect of radiation treatment or a side effect of certain drugs.

Presentation

Population

  • Elderly people, patients undergoing head and neck cancer therapy, patients with autoimmune diseases
  • Medically compromised patients, such as those with diabetes mellitus

Risk Factors

  • Tobacco use
  • Mouth breathing habit

Signs

  • Tongue blade sign: when you touch the oral mucosa with a tongue blade, it will stick to the oral tissues.
  • Lipstick sign: the lipstick will stick to the labial surface of maxillary anterior teeth.
  • Cervical caries and candidacies

Symptoms

  • Pain severity: none
  • Sticky, dry feeling in the mouth and throat
  • Frequent thirst
  • Burning or tingling sensation in the mouth, especially on the tongue
  • Problems speaking or difficulty tasting, chewing, and swallowing
  • Hoarseness, dry nasal passages, sore throat
  • Bad breath
  • Sores in the mouth, sores or split skin at the corners of the mouth, cracked lips
  • Dry, red, raw tongue (when there are superadded candidal infections)

Investigation

Rule Out Other Pathologies

  1. Assess the patient's medical history: Inquire about diabetes mellitus, collagen disorders such as rheumatoid arthritis (in association with Sjögren syndrome), psychological problems, HIV/AIDS, sarcoidosis, herpes virus, hepatitis C virus, end-stage renal disease (uraemia causes dry mouth), and any history of radiation therapy or intake of any medications.
  2. Ask patient about the following:
    • Describe the amount of saliva you have in your mouth: too much, too little, don't know.
    • Do you have difficulty swallowing food?
    • Does your mouth feel dry? Do you need frequent sips of water while chewing food?
    • Have you noticed a change in the taste of food?
    • Do you have difficulties speaking or feel any discomfort wearing dentures?
    • Do you experience dryness of eyes and joint pains?
  3. Perform a complete extraoral and intraoral examination:
    • Examine lips for cracks, fissures, corners of mouth or erythema.
    • Examine salivary glands (unilateral or bilateral salivary gland enlargement).
    • Examine the parotid gland for any facial asymmetry or lifting of the ear lobes that may suggest a salivary gland enlargement.
    • Examine the submandibular salivary glands for any swelling in the lower face or chin. Check for extension of borders and tenderness. A bimanual examination is useful in differentiating the submandibular glands from an enlarged submandibular lymph node.
    • When palpating the salivary glands, look for drooling of saliva or pus discharge from the salivary duct openings. Check for pooling of saliva in the floor of mouth.
    • Examine the tongue and check for depapillation or white plaques that rub off, suggesting pseudomembranous candidiasis.
    • Examine teeth for caries. Cervical caries are most common in patients with xerostomia.
    • Check for enlargement of lymph nodes, which may be a sign of autoimmune disease.
  4. Perform a radiographic investigation: Bitewings and periapical radiographs can be taken to check for dental caries. In addition, prescribe radiographs, such as mandibular occlusal or posterior/anterior view, to verify whether stones are present in the salivary glands.

Diagnosis

  • Clinical examination and clinical signs
  • Medical history
  • Radiographic investigation, if applicable

Treatment

Common Initial Treatments

  1. Topical and Symptom Management Frequent sips of water, letting ice melt in the mouth, restricting caffeine intake, eliminate use of alcohol-based mouth rinses, using a humidifier, and coating lips with petroleum jelly. Caphosol®
    • for mucositis symptoms: swish and spit 4-10 doses/day (at onset of chemotherapy or radiation therapy)
    • for xerostomia: swish and spit 2-10 doses/day

    Numoisyn™

    • Liquid: use 2 mL as needed
    • Lozenges: dissolve 1 slowly (maximum 16 lozenges/day)

    Oasis®

    • Mouthwash: rinse mouth with ~30 mL twice/day, or as needed (do not swallow)
    • Mouth spray: 1-2 sprays as needed (maximum 60 sprays/day)

    Biotène®

    • Oral balance gel: use after meals, at bedtime, and as needed
    • Dry mouth toothpaste
    • Moisturizing mouth spray
  2. Refer to an oral medicine specialist (OMS) if suspecting Sjögren syndrome. Further imaging modalities (MRI scan), sialography, salivary scintigraphy, or labial salivary gland (lip) biopsy may be required. The OMS may prescribe saliva stimulants such as pilocarpine hydrochloride (Salagen®) and bethanechol, and the prescription will take into consideration the patient's medical history. Salagen® 5-mg tablets: take 1 tablet 3 times/day. Titration up to 10 mg 3 times/day may be considered for patients who have not responded adequately. Do not exceed 2 tablets/dose.
  3. Other examinations may include stimulated and non-simulated salivary flow rates (normal salivary flow rate of 1.0 mL/min or greater—hyposalivation is clinically significant at a flow rate of 0.16 mL/min), blood tests, and other serological investigations.
  4. Refer to an ophthalmologist or rheumatologist for diagnosing Sjögren syndrome, systemic lupus erythematosus, and rheumatoid arthritis. The referral can be made by the patient's physician or OMS.

Advice

  • Advise the patient to undergo a topical fluoride application and to rinse their mouth after eating to avoid caries. Patients should be aware that xerostomia is a lifelong condition and that they should maintain good oral hygiene.
  • If dry mouth is caused by systemic medications, refer the patient to their treating physician to explore the possibility of discontinuing the offending medication or changing it with less xerostomic effect.

THE AUTHOR

 

 

Dr. Auluck is a clinician research fellow with the British Columbia Oral Cancer Prevention Program, Vancouver, BC.

 

Acknowledgement: I am grateful to Dr. Michele Williams for her help in creating and revising this article. Michele was an oral medicine specialist and clinical professor in dentistry at the University of British Columbia and an oral medicine leader at the BC Oral Cancer Prevention Program. She passed away in January 2015.

Suggested Resources

  1. Furness S, Worthington HV, Bryan G, Birchenough S, McMillan R. Interventions for the management of dry mouth: topical therapies. Cochrane Database Syst Rev. 2011;(12):CD008934.
  2. Porter SR, Scully C, Hegarty AM. An update of the etiology and management of xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(1):28-46.
  3. Rees J H. Paraneoplastic syndromes: when to suspect, how to confirm, and how to manage. J Neurol Neurosurg Psychiatry. 2004;75(Suppl II):ii43–50.
  4. Thomas BL, Brown JE, McGurk M. Salivary gland disease. Front Oral Biol. 2010;14:129-46. Epub 2010 Apr 20.
  5. Napeñas JJ, Brennan MT, Fox PC. Diagnosis and treatment of xerostomia (dry mouth). Odontology. 2009;97(2):76-83. Epub 2009 Jul 29.
  6. Zunt S. Evaluation of the dry mouth patient. Alpha Omegan. 2007;100(4):203-9.
  7. Navazesh M, Kumar SK. Xerostomia: prevalence, diagnosis, and management. Compend Contin Educ Dent. 2009;30(6):326-8, 331-2; quiz 333-4.
  8. Minor JS, Epstein JB. Burning mouth syndrome and secondary oral burning. Otolaryngol Clin North Am. 2011;44(1):205-19.
  9. Fenoll-Palomares C, Muñoz-Montagud JV, Sanchiz V, Herreros B, Hernández V, Mínguez M, et al. Unstimulated salivary flow rate, pH and buffer capacity of saliva in healthy volunteers. Rev Esp Enferm Dig. 2004;96(11):773-83.

Add new comment