DRY MOUTH: PATIENT MANAGEMENT STRATEGIES: AN INTERVIEW WITH ANN ESHENAUER SPOLARICH, RDH, PHD

DATE: Oct 08, 2015

Question: You treat older adults. How often do you encounter patients with dry mouth?

Response: Dry mouth is a very common condition among my patients and it can be challenging to manage this problem, because it impacts my patients’ comfort level, ability to function and their risks for a host of related problems.

Question: What types of problems are associated with dry mouth?

Response: I would say that the leading problem that my patients complain about is that they are not comfortable. Some report feeling dry and parched, while others feel that their mouth is sticky, or that they have a bad taste in their mouths. Others complain more of bad breath, which frequently accompanies dry mouth. When there is an actual lack of saliva, patients may experience difficulty with speaking, chewing, wearing their dentures and swallowing due to the loss of lubrication. It is important to ask about swallowing, because many older adults have challenges with chewing due to diseased or missing teeth, and then they are unable to break down their foods into small enough pieces to swallow, which causes frequent episodes of choking and possibly indigestion as well. I don’t think that we always remember that saliva is essential to digestion, and that GI complaints are often related to dry mouth. These are among the most common complaints that I encounter related to comfort and function.

Question: Are there other oral problems related to dry mouth?

Response: Yes, most notably risk for a variety of oral infections. Saliva contains immunoglobulins that offer natural protection against bacteria, fungi and viruses, so in a patient who has decreased salivary flow, risk for infections caused by these organisms increases dramatically. This is why we see so many problems with bacterial infections, like caries and gingival diseases, as well as opportunistic fungal infections in the mouth, and increased breakouts of herpetic lesions. Clinicians may also notice very friable mucosa, a fissured tongue, chapped lips and cracking at the corners of the mouth. Loss of lubrication also causes patients to accidentally bite themselves, so I frequently see signs of cheek bite, trauma to the tongue and traumatic ulcerations on the mucosa.

Question: How do you approach the topic of dry mouth with your patients?

Response: I ask all of my patients about whether or not they perceive dry mouth. Some people have had dry mouth for so long that they no longer think to mention it. Others just think that it is a normal part of aging, which it is not. Most know if their medications are causing their dry mouth and are looking for ideas to get some relief. Many have tried multiple products to get relief and are unhappy with the results.

Question: What do you tell your patients to do to get relief and to keep their mouths healthy?

Response: First and foremost, I tell my patients to stay hydrated. You might be surprised about how hard it is to get older adults to drink enough water. Many of my patients are reluctant to drink more water because they are on diuretics and/or have diabetes, so they already have to urinate frequently and they don’t want to add to that challenge. A related challenge is for patients with chronic kidney disease which often requires restrictions on their daily fluid intake. These medically complex patients make it extremely hard to stay hydrated. I like to recommend lubricants to help make the mouth feel moist which adds to comfort; however, not all products offer relief for all patients. I think that we make a mistake by assuming that one given product line will work for everyone. For example, I find that my patients who feel “sticky” do not respond well to products that contain glycerin. I like to have samples of many products, and there are also different delivery vehicles, like sprays, lozenges, rinses and gels, so that they can find the product that is the best fit in terms of convenience and relief. I like using xylitol, but patients who are very dry may overuse the product, and of course, then they experience GI upset, one of the notable adverse events with this intervention. So explaining the right xylitol dosage is very important. I am also a big advocate of therapeutic dentifrices, like Colgate Total, and therapeutic mouthrinses that are available which can be used daily, like those that contain CPC and essential oils. These products all reduce biofilm, which helps to minimize associated disease risks.

Question: What about fluoride for this population?

Response: I am a big fan of prescription fluorides for patients with dry mouth, as medication-induced dry mouth is a leading risk factor for both coronal and root caries in older adults. I always choose a fluoride product with a formulation that is specifically designed to help with dry mouth symptoms as well, and my go-to prescription fluoride is Prevident Dry Mouth formulation. There are also OTC fluoride mouthrinses that are formulated to help soothe dry mouth symptoms in addition to the hard tissue benefits. The level of risk determines whether a prescription product is needed over an OTC product. I recommend that clinicians use a caries risk assessment tool to determine what other interventions may be appropriate for their patients with dry mouth. I always apply fluoride varnish at the end of every dental hygiene appointment for my older adult patients as a standard part of my preventive treatment.

Question: Any other thoughts?

Response: Yes. Don’t assume that everyone with salivary changes will be symptomatic. For example, many patients use medications that alter the quality of the saliva more than the quantity, so these patients may demonstrate signs of oral disease without even being aware of the problem. Also, work closely with patients on biofilm management, because a dry mouth also results in a more acidic oral environment, and the biofilm itself will become more acidic and pathogenic. I love power toothbrushes, flossers and oral irrigators, which are all especially helpful to my patients who have a lot of restorative work making plaque removal difficult. Again, the benefit of adding a therapeutic dentifrice and/or mouthrinse to the regimen will help to control the biofilm, and rinses offer the added benefit of accessing the entire mouth. It is critical to have patients clean their dentures daily to prevent oral bacterial and fungal infections. All patients with dry mouth should be encouraged to use lip balms to keep their lips soft and hydrated to prevent chapping, cracking and bleeding.

This article is brought to you by the Colgate-Palmolive Company. The views and opinions expressed by the author do not reflect the position of the Colgate-Palmolive Company.