It is important to examine the mouth and oral mucosae when a patient experiences dry mouth, and a pen torch to give adequate illumination is essential. The condition of lips, gums and teeth should be assessed and the amount of saliva noted.
In advanced xerostomia, an erythematous, pebbled, cobblestoned, or fissured tongue and atrophy of the filiform papillae can be seen. The surfaces may be erythematous and appear parched.22 It is important to examine under the tongue, so pathology in this area is not missed.
Patients should be asked to remove any dentures, so that all surfaces can be observed. Palpating a dry oral mucosa may result in the examiner’s fingers adhering to mucosal surfaces. Check for coexisting pathology, such as oral thrush.
The observation of patients while they are eating, especially when they are attempting to eat dry foods, such as biscuits or bread, can reveal a prolonged and laboured chewing time. Other features, such as halitosis, cracked lips and fissures, may be present in these patients. If the patient is on oxygen therapy, check to see if it is humidified.
Therapy and symptomatic treatment
All strategies should first aim to address reversible causes of xerostomia. The patient’s medications should be studied to consider whether any can be stopped or reduced. Alternatives may have fewer antimuscarinic properties. Any underlying infections, such as candidiasis, should be treated with antifungal tablets, suspensions (such as nystatin) or gels (miconazole).
Patients who are mouth-breathing should be tried on a short-term course of topical nasal decongestants. Dry mouth may be due to overwhelming anxiety, so this possible cause also needs to be addressed.
Practical options for symptomatic treatment can provide relief. Sipping water throughout the day may be sufficient for some patients. Holding ice chips in the mouth to provide some moisture can also alleviate symptoms. Other measures include sucking on pineapple slices, frequent sips of cold orange squash or semi-frozen fruit juice, or the use of sugar-free chewing gum. Patients may find using olive oil useful and some dry mouth products containing olive oil have been shown to be beneficial.23
Saliva substitutes have been developed for patients with xerostomia. There are a variety of formulations, including rinses, aerosols, chewing gums and dentifrices, and these may also have a role in promoting salivary gland secretions.24 It may help patients to use these formulations before meals.
Dentate patients should use fluoride-containing saliva substitutes and maintain scrupulous oral hygiene. Gels might be more useful overnight, because they take longer to disperse. Acupuncture has been shown to have some benefits in patients with xerostomia.25 Some things are best avoided. Lemon juice quickly depletes salivary glands of saliva, and commercial mouth rinses containing alcohol may lead to desiccation of the oral mucosa. Saliva substitutes may contain animal mucin, usually porcine, and some patients may not wish to use them.
Systemic treatment with pilocarpine is sometimes used following radiotherapy and in Sjogren’s syndrome. This is a parasympathomimetic drug that can increase salivary gland secretion. However, there are a number of side-effects.26 It can cause cardiac arrhythmias and should be avoided in patients with significant cardiac conditions; it is contraindicated in uncontrolled asthma and narrow-angle glaucoma.
|Dr Mark Taubert is a specialist registrar in palliative medicine at the University Hospital of Wales. Competing interests: None declared|
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Originally published in the March 2009 edition of MIMS Oncology & Palliative Care.