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The Management and Treatment of Xerostomia from the Patients Perspective

An Overview by Jenifer Shakes

Common causes of xerostomia Damage to the salivary glands: auto-immune diseases (sjogren's syndrome, rheumatoid arthritis, chronic graft-versus-host disease, systemic lupus erythematosus, scleroderma), radiation therapy to the head and neck, surgery, HIV disease, chronic sarcoidosis, hepatitis C virus infection Interference with neural transmission: drugs, psychogenic disorders (depression, anxiety), autonomic dysfunction (ganglionic neuropathy), conditions that affect the central nervous system (Alzheimer's disease), trauma, paralysis of the facial nerves, decrease in mastication. Water loss/dehydration: reduced water intake (impaired consciousness, damage to hypothalamus), loss of water through the skin (fever, sweating, burns), blood loss, diarrhoea, emesis, hyperventilation, altered renal function (diabetes insipidus, diabetes mellitus), protein and calorie malnutrition. Other: Acute infections

Background

Xerostomia is the subjective feeling of dryness of the mouth. This is usually the result of a reduction in normal salivary flow. The prevalence of dry mouth ranges from 14-46% in the adult population. It is more prevalent in females than males by 5-12% and the prevalence increases with age. Drugs are the most common cause of xerostomia (over 400 drugs are associated with xerostomia). Sjogren's Syndrome is the most common disease to cause xerostomia. Saliva has many functions and there are a number of complications associated with xerostomia, many of which can affect a person's health-related quality of life. The number of symptoms suffered by xerostomic patients varies and the management and treatment of each patient is individualised. Xerostomia can affect a person's health, diet, lifestyle and social life. Very few studies have investigated the affect xerostomia has on diet and on a person's nutritional status.

Physiological functions of saliva 1. Lubricant: protects against mechanical, thermal, & chemical irritation, aids in speech & swallowing. 2. Contains calcium and phosphate ions: facilitate the remineralisation of the teeth. 3. Contains antibacterial proteins: stop the adhesion of specific bacteria to the oral tissues. 4. Contains carbonate & phosphate buffers: Maintain the intraoral pH near neutrality preventing the demineralization of teeth after eating. 5. Clears food debris from teeth and the oral mucosa. 6. Contains amylase: starts the digestion of carbohydrates. 7. Dissolves food to allow for the sensation of sweet, sour, salty and bitter tastes. Complications of xerostomia · increased frequency of dental caries · increased tendency towards candidal infection · gingivitis · dysarthria · dysphagia · dysgeusia · burning tongue · oral mucosal soreness · dry sore cracked lips · salivary gland enlargement · bad breath · heart burn · oesophagitis · aggravated acid reflux

Aim

To investigate the symptoms and problems caused by dry mouth and how these are managed by patients and to make practical recommendations for a patient education resource on the management and treatment of dry mouth.

Methods

The study received ethical approval from the Canterbury District Health Board Ethics Committee. All subjects gave written informed consent. Subjects with xerostomia were recruited from within the Christchurch Region: by Arthritis Society Educators from the Christchurch Arthritis Society members' database; from the current caseload of an oral surgeon at the Canterbury District Health Board Oral Health Centre; and from the current caseload of a dietitian working with head and neck surgery patients at Christchurch Public Hospital. A questionnaire for subjects was developed following interviews with Oral Surgeon, Professor Ferguson, and a Former Leader of Christchurch's Sjogren's Support group who also has Sjogren's Syndrome. Questions were asked on: the duration, cause and severity of the participants' dry mouth; products participants used to manage dry mouth (efficacy & brands); questions about how participants managed their symptoms of dry mouth; questions on problematic foods, avoided foods, `OK' foods, taste acuity, cooking methods, and condiments used by participants; dental cares carried out by the participants; the social and lifestyle effects of dry mouth; sources of advice and suggestions for useful resources. Responses to the qualitative questions were analysed to identify common themes across participants.

Key Findings

41 subjects filled in and returned the questionnaire. Two subjects' questionnaires were excluded from the results because they no longer suffered from dry mouth.

Characteristics of Subjects:

Causes: 26 Sjogren's Syndrome, 4 Radiation Therapy, 2 Oral Lichen Planus, 1 Drug, 1 Lupus, 1 New Dentures, 4 Unknown Sex: 4 Male, 35 Female Age: 29-86 years (69.2 ± 13.2) Ethnicity: 36 NZ European, 1 Maori, 1 English, 1 North American Caucasian Duration of dry mouth: 0.2-30 yrs (11.2±8.2)

Symptoms

Frequent dental cavities* Inflamed gums Difficulty speaking Difficulty swallowing Abnormal/impaired sense of taste Oral Candidiasis Burning tongue Sore tissues lining the inside of the mouth Dry/Sore cracked lips Cracking in the corners of the lips Salivary Gland enlargement

* Includes subjects with all or some own teeth

No/total 16/26 16/39 20/39 25/39 19/39 17/39 25/39 25/39 26/39 18/39 10/39

(%) (62) (41) (51) (64) (49) (44) (64) (64) (67) (46) (26)

Dietary

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15 subjects experienced taste changes due to dry mouth · Spicy food affected 26 subjects' mouths and acidic food affected 29 subjects' mouths · Acidic food affecting the mouth was significantly associated with sore tissues lining the inside of the mouth · 28 subjects added sauces/gravies to their food to make it easier to eat · 31 subjects sipped water with their meals to make it easier to swallow their food · Swallowing difficulties were significantly associated with adding sauces/gravies and sipping water · Common hard to eat foods: meat, dry food, baked products, biscuits, bread, crackers, spicy food · Commonly avoided foods: Spicy food, acidic food/fruit, biscuits, baked products, bread, dry foods, meat · Common problematic spicy foods: curry, chilli · Common problematic acidic foods: oranges, vinegar, lemon, kiwifruit, tomatoes, pineapple · Common easy to eat foods: soup, yoghurt, cooked vegetables, mashed/creamed potatoes, eggs, custard, food prepared with sauces/gravies, casseroles/stews, certain fruits, banana, fish, moist food, soft food

Dental

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Experiencing frequent dental caries was significantly associated with avoiding eating foods and/or drinks considered risk factors for dental caries, for example, carbonated beverages, juice/cordial, sugar in hot drinks, sweets, lollies, cakes, and desserts. Dentures were significantly associated with inflamed gums

Lifestyle

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Dry mouth affected subjects' social life by affecting speech, increasing fluid requirements and making eating out difficult. Some subjects no longer enjoyed eating out because of the limited range of food they could eat and because they had to eat slowly, drink lots and they felt embarrassed. Xerostomia affected some subjects speech and they could not talk for any length of time and some subjects avoided talking to people. 28 subjects would find a pamphlet useful and 8 subjects said a recipe book would be useful. Some of the information subjects wanted covered in a resource included: how to treat and relieve dry mouth, new discoveries and treatments, and information on diet and recipes.

Nutrition Education Resource

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Discussion

Xerostomia places a number of limitations on diet. Subjects tended to avoid dry absorbent food and food that required a lot of chewing. Dry foods may irritate the oral mucosa because they have no moisture in them to help saliva wet the surface of food. Adding sauces and gravies to food is one way of managing this problem. The foods subjects found easy to eat were soft and required little chewing. However, it is important that people with xerostomia have some food that requires chewing as chewing produces saliva and avoiding chewing may cause disuse atrophy of the masticatory muscles over time. Food choice is not only restricted by chewing and swallowing difficulties, but also by acidic and spicy foods that affect the mouth and by foods that are considered risk factors for dental caries (in dentate subjects). Such a limited food choice may have the potential to cause nutritional inadequacies. The results of this study indicate that xerostomia has the potential to decrease quality of life. It affects two of the main factors that play a role in social occasions, communication and food. Having difficulties speaking and being limited to a narrow range of food choices detracts from the enjoyment of social life and even prevents some people from having an active social life.

Recommendations

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A pamphlet containing ideas and tips on how to treat and relieve dry mouth symptoms could be designed using ideas from the questionnaires and the literature. A recipe book could be designed that contains foods that will not aggravate symptoms of xerostomia and are easy to eat with flavours that are not spicy or acidic. Alternatively, a pamphlet could be designed that contains tips on how to modify recipes to make them suitable for xerostomic patients. A resource could be designed for health professionals with information on the causes of xerostomia, common symptoms of xerostomia, and how to diagnose xerostomia and treat its symptoms. Food records could be collected from the subjects and analysed to better understand the nutritional implications of their behaviours.

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