1. DIAGNOSIS AND MANAGEMENT
OF XEROSTOMIA IN THE
ELDERLY PATIENT

2. Salivary Gland Dysfunction and Xerostomia (Dry Mouth)

4. XEROSTOMIA
Xerostomia (dry mouth) is defined as a subjective complaint of dry mouth that may result from a decrease in the production of saliva.

5. XEROSTOMIA
It affects 17-29% of samples populations based on self-reports or measurements of salivary flow rates.
More prevalent in women.
Can cause significant morbidity and a reduction in a patient’s perception of quality of life.

6. SALIVA
It keeps the teeth healthy by providing a lubricant, calcium and a buffer.
It also helps to maintain the health of the gums, oral tissues (mucosa) and throat.
It also plays a role in the control of bacteria in the mouth.

7. It helps to cleanse the mouth of food and debris.
It provides minerals such as calcium, fluoride, and phosphorus.
It helps in swallowing and digesting food.

8. Lack of saliva will make the mouth more prone to disease and infection.
Lead to a burning feeling.

12. Antimicrobial Factors in Human Whole Saliva
Non-immunoglobulin Factors Origin
Lysozyme Salivary glands, crevicular fluid (PMNs)
Lactoferrin Salivary glands, crevicular fluid (PMNs)
Salivary peroxidase Salivary glands
SCN- Salivary glands, crevicular fluid
H2O2 Salivary glands, crevicular fluid (PMNs),
bacterial and yeast cells
Myeloperoxidase Crevicular fluid (PMNs)
Cl- Salivary glands, crevicular fluid
Agglutinins, aggregating proteins Salivary glands
Histidine-rich polypeptides Salivary glands
Proline-rich proteins Salivary glands
Immunoglobulin Factors
Secretory IgA Salivary glands
IgA, IgG, IgM Crevicular fluid

13. Ionizing radiation can injure the major and minor salivary glands which may lead to atrophy of the secretory components and results in varying degrees of temporary or permanent xerostomia.
Toxic substanaces in chemotherapeutic agents.

14. Diabetes mellitus: Patients with poor glycemic control, are more likely to complain of xerostomia and may have decreased salivary flow.

15. Dry Mouth With Strawberry Tongue

16. Severe Dry Mouth (Strawberry Tongue)

17. Other Conditions Anxiety or Depression HIV Diabetes, Type 1 or 2 AIDS
Primary Biliary Cirrhosis
Bone Marrow Transplantation
Vasculitis
Graft-vs.-Host Disease
Chronic Active Hepatitis
Renal Dialysis

18. Salivary Gland Dysfunction and Xerostomia
Clinical Appearance:
Oral mucosa appears dry, pale, or atrophic.
Tongue may be devoid of papillae with fissured and inflamed appearance.
New and recurrent dental caries.
Difficulty with chewing, swallowing, and tasting may occur.
Fungal infections are common.

19. Pale Fisured Tongue Due To Severe Dry Mouth

20. Moderate Xerostomia

21. Warning Signs in Xerostomia
1. Dry, burning mouth and throat
Dry, cracking lips, especially in the corners. The cracks may be tender and/or bleed
Problems with denture wearing

22. Problems eating and swallowing food
Difficulty with speech due to mouth soreness.
6. Increased caries and periodontal disease

23. Diagnosis of Xerostomia
It has been estimated that a 50% reduction in salivary secretion needs to occur before the xerostomia becomes apparent.
An affirmative response to at least one of the five following questions about symptoms has been shown to correlate with a decrease in salivary flow:

24. 1. Does your mouth usually feel dry?
2. Does your mouth feel dry when eating a meal?
Do you have difficulty swallowing dry food?
Do you sip liquids to aid in swallowing dry food?

25. 5. Is the amount of saliva in your mouth too little most
of the time, or don’t you notice it?
When unstimulated salivary flow is less than 0.12 to 0.16 ml/minute, a diagnosis of hypofunction is established.

26. MANAGEMENT
The general approach to treating patients with hyposalivation and xerostomia is directed at palliative treatment for the relief of symptoms and prevention of oral complications:

27. Consult with physician to decrease drug dose, alter drug dosages, or substitute one xerostomic medication for a similar-acting drug with fewer salivary side effects.

28. Symptomatic Treatments:
Sip water frequently all day long
Let ice melt in the mouth
Restrict caffeine intake
Avoid mouth rinses containing alcohol
Humidify sleeping area
Coat lips with lubricant.

29. Coat the lips with a petroleum jelly like Vaseline, Blistex, or lanolin.
Maintain good oral hygiene. Floss daily.
Brush at least twice a day.
Use toothpaste with fluoride and alcohol free (e.g. Biotene toothpaste).

30. Avoid Tobacco use, spicy, salty, and highly acidic foods that irritate the mouth.

31. Saliva Substitutes: Rx:
Sodium carboxymethyl cellulose* 0.5% aqueous solution [OTC]
Disp: 8 fl. Oz.
Sig: Use as a rinse as frequently as needed.
*Generic carboxymethyl cellulose solutions may be prepared by a pharmacist.

32. Commercial Salivary Substitute
Commercial oral moisturizing gels (OTC) includes:
OralBalance.
XERO-Lube
Salivart
Moi-Stir Orex
Optimoist

33. Commercial Oral Moisturizing Gels [OTC]:
Laclede Oral Balance

34. Oral Balance Ingredients
Polyglycerylmethacrylate
(moisturizing agent)
Lactoperoxidase (antibacterial)
Glucose Oxidase (antibacterial)
Lysozyme (antibacterial)

37. Saliva Stimulants:
The use of sugar free gum, lemon drops or mints are conservative methods to temporarily stimulate salivary flow in patients with medication xerostomia or with salivary gland dysfunction.

38. Rx: Biotine chewing gum [OTC] Disp: 1 package
Sig: Chew as needed. Due to problems of abrasion of the mucosa under the denture and potential adhesion of the gum to the denture, use caution if the patient has removable dentures.

39. Rx: Pilocarpine HCl (Salagen) Tablets 5 mg Disp: 21 tablets
Sig: Take 1 tablet tid 1/2 hour prior to meals. Dose may be titrated to 2 tablets tid.
Some authors recommend using 1 tablet of pilocarpine 4-5 times daily.

40. Rx: Pilocarpine HCL solution 1 mg/ml Disp: 100 ml
Sig: Take 1 teaspoonful tid.

41. Pilocarpin HCl May need 2-3 months to determine effectiveness.
Side effects include sweating and diarrhea.
Avoid in patients with narrow angle glaucoma, severe asthma, pulmonary diseases.

42. Rx: Cevimeline (Evoxac) Capsules 30 mg Disp: 21 tablets
Sig: Take 1 tablet tid.

43. Rx: Bethanechol (Urecholine) tablets 25 mg Disp: 30 tablets
Sig: Take 1 tablet up to 5 times daily.

44. Conditions Affecting the Tongue

45. Conditions Affecting the Tongue
Geographic tongue
Hairy tongue
Fissured tongue
Varices
Vitamin deficiencies

46. Benign Migratory Glossitis (Geographic tongue)
Etiology:
Unknown
May be associated with psoriasis and Reiter’s syndrome.
Appearances:
Changing pattern of erythematous patches on the tongue dorsum caused by atrophy of the filiform papillae.

47. Geographic Tongue

48. Hairy Tongue Etiology: Antibiotics Tobacco Chlorhexidine Food debris
Oral candidiasis

50. Black/Brown Hairy Tongue

52. Brown Hairy Tongue

53. Hairy Tongue Treatment: Proper oral hygiene and tongue brushing.
If a fungal infection is suspected, perform a fungal culture and use topical antifungal.

54. Fissured Tongue Etiology: Unknown Appearance:
Numerous small furrows and fissures on the dorsum of the tongue. May be attributed to trauma, vitamin deficiencies, salivary gland dysfunction.

56. Nutritional Deficiencies
Etiology
Vitamin B1, B2, B6, B12 and folic acid deficiency.
Appearance
Loss of filiform papillae produce a painful erythematous and granular appearing tongue.
Eventually papillae atrophy leaving a smooth/bald tongue.