Finding Relief From Dry Mouth

Arid-Grass-Field

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:

  1. cavities and tooth decay
  2. periodontal disease
  3. 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:

  1. 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

  2. Barewal R, Shune S, Siegel S. The Oral Dissolution Rate of Transitional Snack Foods in Adults with and without Dry Mouth.  In press, 2019.

  3. 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

  4. 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

  5. Scully C. Drug effects on salivary glands: dry mouth. Oral Dis. 2003;9(4):165-176.

 

Learn more

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.  

Parkinson’s and the Eyes

Looking through Lens of Glasses

Contributed By Carol Pfeil

Eyesight is an astounding process. My eyes pick up light, and depending upon how close or far away the object is, the lens changes shape, shoots the image back to the retina, then the image of that object is sent via the optic nerve upside down to the brain where my brain flips it and gets the message that a cute, non-house-broken, 13 pound black and white Shih Tzu with a red bow, named Obi Wan, has just jumped onto my lap.

However, with PD’s breakdown in the production of dopamine in the mid-brain or gut, it is common to develop a number of eye movement difficulties. These problems may include dry eye due to a decreased blink rate with PD; eye movements that become slow or dysfunctional causing the eyes to not converge normally, or track. Visual hallucinations are also possible. Any one of these things, or all, can affect one’s ability to read, watch TV, or walk (which could warrant a fall) – that terrible 4 letter word.

We know that everyone’s PD manifests differently, and that includes eye movement issues as well. Most of us would agree that knowledge is power and concerns or problems are usually less frightening when discussed, named (if possible), and analyzed by an experienced medical professional. (Additionally, if I had a choice, I would choose one with a sense of humor.) 

One such experienced and humorous physician, Dr. Scott Stevens, a Bend Ophthalmologist, recently taught us some anatomy-class-vocabulary and detailed some important information about PD’s effect on the eyes through a recent PRO webinar. (View the recording at youtube.com/user/ParkinsonsResources.) The very good news is that often a trip to an eye doctor can result in some very good solutions or at least accommodations for the problems. Some of these mitigators may include near or distance corrective glasses (or prisms added to glasses), walking assistance devices, or eye drops/ointments.

The most reported and common eye problem for those with PD is dry eye or Kerstoconjunctivitis Sicca. These challenges are often due to: 

  • A decreased blink rate (4-6 times a minute vs the non-PD 12-18 blinks per minute causes eyes to be drier)
  • Blepharospasm (which causes abnormal and involuntary spasms of the eyelid resulting in eyelid closure),
  • Apraxis of the eyelid opening (results in difficulty opening the eyes) and
  • Blepharitis (inflammation of the eyelid margin)

These conditions are very common and are often eased with artificial tear eye drops or ointments. If you have tremor, the ointments may be your best bet. Other recommendations for dry eye treatment include applying a damp washcloth to the eyes and covering that with a gently microwaved seed infused sock (or other warmed pad) for a few minutes twice a day to increase eye moisture.

Other eye movement difficulties with PD are saccades (or eye movement). Saccade problems include:

  • Inability to use both eyes at once to see or follow a moving object (Accommodative paresis or convergency insufficiency)
  • Difficulty maintaining fixation on an object (impaired smooth pursuit)
  • Slowed response to moving the eyes toward a new target (prolonged saccade latency)
  • Eyesight undershooting a new target when your eyes move (hypometric saccades)
  • Impaired ability to think and orient in different dimensions (visuospatial dysfunction)
  • Difficulty moving the eyes back to a remembered target (impaired antisaccade)

This eye movement problem as a result of the saccades makes it difficult to read with both eyes working together for any extended period of time. It may also cause a person to experience balance issues, which can make the correction a tricky fix. Treatment may include single vision glasses for reading or changing the prism in the lens to mitigate the visual problems. Dr. Scott’s “simple” answer? Read with one eye – or try using a ruler to keep your place on the page, choosing large print books or an I-pad/e-reader for easier viewing.

Accommodations for the balance issues include distance glasses (not bifocals) and a cane or walker to maintain one’s posture, as not seeing in 3D often causes objects to look flat and navigating space can be problematic. 

Lastly, it is common for those with PD to experience visual hallucinations, impaired color discrimination, and decreased contrast sensitivity.  

With impaired color discrimination, colors may appear muted, but a person doesn’t usually test positive for color blindness. 

With decreased contrast sensitivity, it’s difficult to see well in low light.

With impaired depth perception, things like steps may not be seen, resulting in falls.

With visual hallucinations, a person may see things that aren’t really there or experience double vision.

Because many of these symptoms related to color, contrast, depth, hallucinations, and double vision can exhibit similarly to a cataract condition, it can become difficult to know what’s caused by the PD and what’s unrelated. For those with PD experiencing these symptoms, creating special prisms in eye glasses can often allow someone to read more successfully.

The importance of a regular and thorough eye exam, along with discussion and evaluation by an Ophthalmologist, is important in increasing one’s quality of life with PD. At PRO, we believe that quality of life is always worth pursuing. Armed with knowledge, hope, and a little courage, keep moving forward and let us know how we can do to support you. Perhaps it doesn’t apply outside of the British political arena, but as the idiom says, “The eyes (ayes) have it. Salud!

Originally published in the July 2019 Parkinson’s Perspective

Learn more

Learn more about Parkinson’s disease and the eyes by watching PRO’s webinar by Dr. Scott Steven’s. Find this topic and others when you visit our YouTube channel

Ping Pong for PD

Ping-Pong-Table

Contributed by Carol Pfeil

Whether you know the game as Whiff-Waff, Pim-Pam, Flim-Flam, Gossima, Netto, Parlor Tennis, Table Tennis, or Ping Pong – it’s all the same, at least in its English origins as a brilliant after dinner substitute activity for lawn tennis. Actually, rules were only created in 1926 after Europeans had played the game for 35 years. Imagine the English without a proper set of rules, but instead just relishing in a ‘jolly good time’. Books stacked high enough to function as a net, a cigar box top as a paddle, and the round part of a champagne cork as the ball were the original equipment. Thankfully, the game has evolved quite a bit since its origins. 

Some may view Ping Pong as more of a ‘Go Fetch’ game, as a fair amount of time ‘playing’ involves chasing stray balls after a more experienced player slams another one right at the corner – but not if you’re one of the 300 million people who play it worldwide. Ping Pong took 100 years to gain the reputation as a legit-enough sport to become an Olympic event in 1988. From hipster table tennis parlors in Portland, independent Ping Pong clubs around the Northwest to PRO headquarters backroom in Beaverton, many seem to enjoy and appreciate the brain enriching activity.  Who knew that the skills involved in Ping Pong can greatly benefit people with Parkinson’s? 

 

More Than A Game

In a 2013 Lancet medical journal article, researchers liken the brain skills demanded from tango dancing, tai chi, and boxing to those found in Ping Pong. (I don’t know about you, but I would rather be seen being a freshman ping pong player in jeans and tennies than an uncoordinated tango dancer in stilettos and a low-cut, short dress.) World renowned Psychiatrist Daniel Amen, M.D. quips about table tennis – “Golf is good. Tennis is terrific. Table Tennis is the best sport in the world.” Why? 

Think about some of the classic PD symptoms, such as imbalance, slowed thinking/strategy skills, slowed gross and fine motor skills, tremor, anxiety, depression, and oftentimes social isolation. Brain research has shown that Ping Pong stimulates 3 different parts of the brain that effect balance, generation of new brain cells, neuroplasticity (new neuropathways being carved out due to vigorous activity), and blood flow to the brain. The truth is that any aerobic activity will give you most of these results as well, but Ping Pong ranks high in the areas of the brain primarily due to anticipating and responding quickly in a small, 9X5 foot area.  

In that small play area, a ping-ponger, by utilizing the prefrontal cortex portion of the brain, anticipates where the ball might land and then stimulates the cerebellum resulting in the fine motor control needed to hit the ball where it needs to go. A third area of the brain, the hippocampus, is also stimulated when a player engages in aerobic exercise from the fast-paced speed of the game. As exertion goes up, this part of the brain begins to create new brain cells and that can continue throughout adulthood. 

Recognizing that playing Table Tennis was helping to improve some of their PD symptoms, two New Yorkers with PD birthed a program in 2017 they coined Ping Pong Parkinson. They organized the program to include warm-up exercises and Ping Pong technique before beginning the game, then partnered each player with a volunteer leader, rotating every 5 minutes, and ending their program with video footage of a Ponger’s skills and progress. (Not going to lie – that sounds terrifying.) Good news! Ping Pong could become your next great obsession and it could be fully justified with its brain benefits, unless you’d rather wear stilettos.  

Organizing Support

Grandparents Walking with Grandchild

Contributed By Heather Balducci

Living with Parkinson’s can make recovery from illness, injury or surgery a long and challenging road.  Care partners of people with PD also need extra support when faced with their own health setbacks in order to ensure that they recover well and have sufficient time to rest and recuperate before returning to their caregiving roles.  

It can be a challenge to ask for support from friends and family when faced with an unexpected need, and organizing support can also be difficult as well.  Most people come to realize that their loved ones and acquaintances are more willing to help than they had expected.  

Here are some steps you can take, as a Person with PD or care partner to best prepare yourself for a planned or unexpected surgery, illness or injury.  

  • Think of specific tasks that will help decrease your stress level.  People often are met with loved ones saying “let me know if there is anything I can do to help,” and having a specific and helpful request in mind can help you direct people in a way that allows them to support you and meets your need. Examples of tasks could include home-cooked meals, short social visits, small tasks around the home, grocery store runs or rides to doctor appointments.   
  • Consider using a website like “Lotsa Helping Hands” (www.lotsahelpinghands.com) to organize support.  This free site allows users to set up a calendar of care tasks, send the calendar and their request to loved ones, and communicate about their progress with those who are offering to help.  If you are not particularly tech savvy, see if someone can set up and manage a care page for you.   
  • When hospitalized, many people need to spend time in a skilled rehabilitation facility before going home.  Be sure that you are talking with the hospital staff assisting you in planning for a rehab stay.  While in rehab, keep in mind that you may have a lot of free time, and it may still be helpful to arrange social visits with friends and family to help boost your mood.   
  • Find out about local services you could use for meals, in home care, house cleaning, or any other needs you may have.  Most communities have a range of services that cover these needs, and a good place to start in finding these is your local Aging and Disability Resource Center at 855-673-2372 (Oregon) and 888-637-6060 (SW Washington).  Also, please consider calling the Parkinson’s Resources of Oregon helpline for ideas and support in connecting to resources in your community.  
  • If you don’t already have an “Aware in Care” Patient safety kit – consider ordering one from the Parkinson’s Foundation (they’re free!).  This kit is a great way to keep your medication information, emergency contacts, and information on Parkinson’s available in one place, and it also provides information on the importance of medication timing and avoidance of medications that complicate PD symptoms.  Having a kit available and prepared can help you and your loved one minimize any complications associated with going to the hospital, ER, or a new medical provider.