Quality Resource Guide l Managing Dental Patients with Xerostomia and Hyposalivation 1st Edition 2 www.metdental.com Xerostomia Xerostomia is the subjective, self-reported complaint of a “dry mouth.” Xerostomia and hyposalivation are typically interrelated, with salivary flow reduced by 50%, creating dry mouth symptoms. However, hyposalivation may be absent despite the complaint of xerostomia, and patients may complain of dryness irrespective of the amount of saliva in the mouth. This can occur because of low humidity, mouth breathing, sensory variability, and inconsistent patient descriptions of their symptoms. Saliva is a complex fluid composed of major and minor salivary glands secretions. These secretions differ in composition, particularly their water, salivary proteins, and mucin content, which may result in varying perceptions or sensations of “wetness” or “dryness.” 3 Clinicians must know that patient symptoms or perceptions may not be reliable measures of xerostomia or salivary gland hypofunction. Introduction This Quality Resource Guide provides readers with a summary of the current knowledge regarding xerostomia and hyposalivation. It contains “evidence-based” recommendations for the practitioner as determined from the latest research and clinical outcomes studies. Practitioners should be aware that evidence continues accumulating that supports current therapies’ efficacy for managing xerostomia and hyposalivation. Over-the-counter (OTC) saliva substitutes and muscarinic agonists are the predominant agents available for the relief of the symptoms of dry mouth. Innovative gene therapies for producing saliva are being evaluated but are not yet available. Saliva Saliva consists primarily of water that continuously irrigates, lubricates, and physically cleanses oral structures. It is essential to oral health. The flow of saliva clears food debris and its degradation products, including bacteria, from the surfaces of the teeth. Enzymes and water in saliva aid digestion, and several innate immune molecules in saliva help fight infection. Bicarbonates, phosphates and proteins in saliva serve as buffering agents against acids that are ingested or generated by bacterial fermentation of simple carbohydrates. Saliva’s electrolytes, calcium and phosphate, help prevent the dissolution of enamel and promote remineralization. Consequently, loss of saliva and these critical constituents can lead to significant dental complications and reduced oral health-related quality of life. 1 Salivary Flow Rate and Hypofunction/Hyposalivation At rest, unstimulated saliva is produced at a rate of about 0.3 to 0.4 mL/min as measured by sialometry (the method for measuring the amount of saliva collected within a specified time). Stimulated saliva (by chewing a piece of paraffin/gum) is produced at a rate of 1.0 to 2.0 mL/min. Hypofunction or hyposalivation is defined as the production of < 0.7 mL/min stimulated whole saliva flow or ≤ 0.1 mL/min of unstimulated whole saliva flow. 2 Hyposalivation is often accompanied by a change of taste, oral burning sensations, and xerostomia. Prevalence & Etiology Xerostomia is an age-related symptom affecting about 10% of 30-year-olds and up to 20% of older adults. 4,5 Xerostomia is commonly associated with medical conditions, medication use, stressful conditions, and hyposalivation. There are numerous causes of hyposalivation that can produce symptoms of xerostomia, and the etiologies can variably affect the function of the major and minor salivary glands: Use of xerogenic medications. There is a large number of medications (over-the-counter [OTC] or prescription) that are xerogenic (Table 1). These medications reduce saliva flow from the major and minor salivary glands through their anticholinergic effects. The effect of xerogenic medications is compounded by polypharmacy used to treat common chronic conditions such as hypertension, cardiovascular disease, diabetes, chronic obstructive pulmonary disease, and urinary incontinence, particularly in an elderly patient. Table 1 - Therapeutic Categories of Drugs That May Reduce Saliva Anorexiants................................................................................................................... Amfepramone (Tenuate®) Antianxiety agent...........................Alprazolam (Xanax®), Chlordiazepoxide (Librium®), Lorazepam (Ativan®) Antispasmodic/anticholinergic agents......................................Benzatropine (Cogentin®), Tolterodine (Detrol®) Anticonvulsants...............................................................Carbamazepine (Tegretol®), Gabapentin (Neurontin®) Antidepressants...................................Fluoxetine (Prozac®), Trazodone (Desyrel®), Buproprion (Wellbutrin®) Antiemetics.......................................................................Dimenhydrinate (Dramamine®), Meclizine (Antivert®) Antihistamines.................................................................Brompheniramine (Dimetane®), Loratadine (Claritin®) Antihypertensives............................................................................Clonidine (Catapres®), Enalapril (Vasotec®) Antiinflammatory analgesics....................................................................Ibuprofen (Advil®), Naproxen (Aleve®) Antineoplastic agents.................................................................Busulfan (Myleran®), Interferon-a (Roferon®-A) Antiparkinsonian agents..................................................................................Carbidopa / Levodopa (Sinemet®) Antipsychotics..................................................Chlorpromazine (Thorazine®), Prochlorperazine (Compazine®) Bladder control ........Oxybutynin (Ditropan XL®) · Tolterodine (Detrol®), Solifenacin (Vesicare®), Tamsulosin (Flomax®) Bronchodilators...............................................................Ipratropium bromide (Atrovent®), Albuterol (Ventolin®) Decongestants............................Pseudoephedrine (Sudafed®), Fluticasone propionate/Salmeterol (Advair®) Diuretics.......Bumetanide (Bumex®), Chlorothiazide (Diuril®), Furosemide (Lasix®), Triamterene (Dyazide®) Muscle relaxants.............................................................Cyclobenzaprine (Flexeril®), Orphenadrine (Norflex®) Narcotic anal ......................Hydrocodone/acetaminophen (Norco®), Oxycodone/ acetaminophen (Percocet®) Sedative hypnotics........................................................................... Diazepam (Valium®), Zolpidem (Ambien®)