This document discusses xerostomia (dry mouth) and its diagnosis and management in elderly patients. Key points include: - Xerostomia affects 17-29% of populations and is more prevalent in women. It can significantly reduce quality of life. - Saliva plays important roles like maintaining oral health, swallowing, speaking and digestion. Lack of saliva increases risks of infections. - Many conditions and medications can cause xerostomia like Sjögren's syndrome, radiation therapy, diabetes, antidepressants. - Diagnosis involves questions about dry mouth symptoms and measuring low saliva flow. - Management focuses on relieving symptoms via saliva substitutes, stim

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 affects17-29%of samples populations based on self-reports or measurements of salivary flow rates. More prevalent inwomen. Can cause significant morbidity and a reduction in a patient’s perception ofquality 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 controlof 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 anddigesting 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 FactorsOrigin 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.

15. Severe Dry Mouth (Strawberry Tongue)

16. 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. Tongue may be devoid of papillae with fissured and inflamed appearance.

19. New and recurrent dental caries.

20. Difficulty with chewing, swallowing, and tasting may occur.

22. Moderate Xerostomia

23. 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

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

25. 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 leastone of the fivefollowing questions about symptoms has been shown to correlate with a decrease in salivary flow:

26. 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?

27. 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 than0.12 to 0.16 ml/minute,a diagnosis of hypofunction is established.

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

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

30. 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.

31. 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 andalcohol free (e.g. Biotene toothpaste).

32. Avoid Tobacco use, spicy, salty, and highlyacidic foods that irritate the mouth.

33. 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.

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

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

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

39. 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.

40. 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.

41. 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.

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

43. 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.

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

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

46. Conditions Affecting the Tongue

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

51. Tobacco

52. Chlorhexidine

53. Food debris

55. Black/Brown Hairy Tongue

57. Brown Hairy Tongue

60. Appearance:

63. Vitamin B1, B2, B6, B12 and folic acid deficiency.

64. Appearance

65. Loss of filiform papillae produce a painful erythematous and granular appearing tongue.