Contributed By Reva Barewal, DDS, MS, Dipl. ABDSM
Everyone experiences dry mouth. That cotton ball sensation in your mouth that makes your tongue feel twice its size. Speech becomes an effort and swallowing difficult. Most healthy adults can trace back the cause to the common culprits- alcohol, caffeine or smoking. Taking a few restorative glasses of water is often the cure. However, 13-28% of older adults face this as a chronic issue, called xerostomia, every day. This number can increase to an alarming 60% of residents in long term care. Loss of quality of life stemming from reduced food enjoyment is a reality. Also, loss of oral health and ultimately overall health raises the need for us to share information regarding this condition across disciplines.
I am a prosthodontist, and French culinary chef with a breadth of research interests ranging from dental implants, geriatric dentistry, and product innovation in the area of therapeutic snack foods for dysphagia. In my private practice, I have to manage many patients with severe xerostomia. They are so easily identified as I can always find a water bottle sitting in their lap, ready to soothe their parched mouths. A common belief is that salivary hypofunction is an age-related change. This is not true at all. It is largely caused by health conditions, hydration and medication. What we will explore is how does the presence of dysphagia (difficulties with swallowing) and xerostomia affect the individual and what can we do to help them.
Dry mouth can result in an overall reduction in quality of life. Sufferers can experience poorer retention of dentures and more denture sores, avoidance of spicy foods and acidic foods, altered speech, swallowing and taste.
As far as oral health, the impact of xerostomia is significant. A loss or reduction of saliva increases risks for:
- cavities and tooth decay
- periodontal disease
- food retention on teeth, tissues and possibly dentures.
These factors alone will increase the patient’s risk of aspiration pneumonia. But when xerostomia occurs in combination with dysphagia, the risk is multiplied. Dysphagia sufferers have an increased risk of hospital readmissions for pneumonia and aspiration pneumonia. Dr. Donna Graville, director of the NW Center for Speech and Swallowing at OHSU shed some light on the added concern with xerostomia. “A patient can be so dry mouthed that crackers turn to dust with chewing and can create a real choking risk in the dysphagia population.”
Do people have dysphagia & xerostomia?
To answer this, we need to understand the main conditions leading to dysphagia in the elderly. These are:
- Stroke
- Progressive neurologic disease
- Dementia
- Head and neck cancer
- Traumatic brain injury
Health Conditions Leading to Xerostomia:
- Parkinson’s Disease
- Depression
- Brain Tumor
- Stroke
- Neurosurgical Operations
- Alzheimer’s disease
- Irradiation
- Excision
- Dehydration
It is hard for a dysphagia sufferer to escape the over 500 medications that cause xerostomia – otherwise known as xerogenic drugs. A classification of xerogenic medications found commonly in the medicine cabinet of a dysphagia sufferer are:
Antihistamines: ex. Benadryl, Claritin, Zyrtec
Antidepressants: ex. Zoloft, Flexaryl and Elavil.
Antiemetics: ex. Anzemet, Domperidone).
Antihypertensives: diuretics, ACE inhibitors, calcium channel blockers, beta blockers
Antiparkinson: ex. Levodopa, Artane
Antispasmodics: ex. Dicyclomine.
Sedatives: ex. Amytal, Valium, Lunesta
Analgesics: opioids ex. Morphine, cannabis
Chemotherapy agent: ex. retinal
Antireflux agents: proton pump inhibitors ex. Omeprazole
Treatment of Xerostomia
There is a lot of frustration for the patient and the clinician in developing a treatment for dry mouth as many times we often cannot cure this problem but do our best to reduce the side effects. If the issue is dehydration, then increasing fluid intake will eliminate the problem. This is an easy solution, but rarely the only solution needed. If the cause is medication, a discussion with the PCP regarding drug scheduling, dosages or changes in medication would be helpful. Palliative support is often necessary though and usually requires a multifaceted approach. Please keep in mind that saliva flow naturally reduces with age.
Dietary: Patients on a TMD should also avoid spicy or acidic foods if they experience burning discomfort. However citrus notes in foods can encourage saliva flow. Meltable foods, such as Savorease crackers, can provide crunchy texture yet still dissolve in dry mouth. Alcoholic beverages, caffeinated beverages, and tobacco use should be reduced. A high fluid intake should be encouraged unless it is medically contraindicated. Tooth brushing after every meal is necessary.
Environmental: Maintenance of optimal air humidification in the home is useful, especially during sleep, as is using vaseline to protect the lips. Saliva substitute gels are often used to coat the oral mucosa and reduce frictional irritation. These can be very useful during sleep when salivary flow can drop to zero.
Dental: Regular visits to the dentist, whether they are dentate or edentulous are important to improve function of dentures, prevent advancement of disease. Oral exams should include an evaluation for the presence of candidiasis. A home-based fluoride preventive program should be incorporated for dentate individuals. An increased frequency of hygiene appointments can also serve to educate on prevention and reduce risks of periodontal disease and dental caries.
Saliva stimulation: Cholinergic drugs such as pilocarpine may be tried, unless medically contra-indicated.
Temporary palliation: Non-alcohol based mouthwashes are useful to alleviate oral discomfort. There are numerous artificial saliva products currently marketed for non-prescription use by patients that can be trialed. If the salivary gland is still functioning, use of xylitol gum can stimulate saliva flow.
The lack of normal salivary function can change texture modification recommendations by the SLP. Recognition of the effects of xerostomia and the additive risks for aspiration pneumonia can encourage more cross-discipline communication between speech language pathology and dentistry as well as increased education for the patient and care givers.
References:
Barbe AG. Medication-Induced Xerostomia and Hyposalivation in the Elderly: Culprits, Complications, and Management. Drugs Aging. 2018;35(10):877-885. doi:1007/s40266-018-0588-5
Barewal R, Shune S, Siegel S. The Oral Dissolution Rate of Transitional Snack Foods in Adults with and without Dry Mouth. In press, 2019.
Humphrey SP, Williamson RT. A review of saliva: normal composition, flow, and function. J Prosthet Dent. 2001;85(2):162-169. doi:1067/mpr.2001.113778
Pace CC, McCullough GH. The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: review and recommendations. Dysphagia. 2010;25(4):307-322. doi:1007/s00455-010-9298-9
Scully C. Drug effects on salivary glands: dry mouth. Oral Dis. 2003;9(4):165-176.
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Reva Barewal, DDS, MS is a clinical assistant professor at Oregon Health Science Center in the department of Pulmonology and Critical Care. She is a prosthodontist, and French culinary chef. She owns a multi-disciplinary private practice in Portland, OR. Her research interests include understanding the influence of transitional foods on food enjoyment and nutrition levels for individuals with dysphagia. She is particularly interested in better understanding the behavior of transitional foods in the mouth and the effects of masticatory function on dysphagia. Her passions lie in improving food enjoyment for all individuals and has created a line of snack supplements for people with swallowing problems that are savory and delicious. Please visit www.savorease.com to find out more.