Brooke D. Fidler, Pharm.D., CDM, Assistant Professor of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University

Dry mouth and oral health

Universal Program Number: 401-000-08-007-H01 Initial release date: June 1, 2008

Planned expiration date: June 1, 2011

This program is worth two contact hours (0.2 CEUs).

Target Audience

Pharmacists in community-based practice.

Program Goal

To increase the pharmacist’s understanding of dry mouth and improve the pharmacist’s ability to provide consultation on appropriate oral health and products used to manage this condition.

Learning Objectives

Upon completion of this program, the pharmacist should be able to:

1. Explain the pathophysiology of dry mouth. 2. List the risk factors and symptoms of dry mouth.

3. Identify those patients who require physician referral versus those who are eligible for self-treatment.

4. Evaluate the different treatment modalities used in the management of dry mouth, including prescription and nonprescription medications.

5. Define his or her role as a pharmacist in the management of patients who suffer from dry mouth, including counseling on nonpharma-cologic treatments.

 

To obtain credit: Answer the questions at the end of this lesson on the answer sheet provided. If you are submitting your answers by mail or fax, completely fill in the circle corresponding to your answer with a black pen (no pencils or blue pens please). A statement of credit will be sent to participants achieving a minimum score of 70 percent correct responses. Statements of credit are issued within seven days of receipt, if submitted by mail or fax, and immediately, if submitted online. TO LINK DIRECTLY TO THIS LESSON CLICK www.cedrugstorenews.com/40100008007H01 Questions regarding statements of credit and other customer service issues should be directed to Angela Sims at (800) 933-9666. Include your seven-digit CEQ enrollment number on the answer sheet. (The seven-digit number immediately to the right of the letters CE on the first line of the label.) Fax to (813) 626-7203 or mail completed answer sheet to DrSN/Pharmacy Practice, P.O. Box 31180, Tampa, FL 33631-3180.Programs also may be completed online at www.cedrugstorenews.com.

INTRODUCTION

Xerostomia, commonly called dry mouth, is a condition in which the mouth is excessively dry due to limited or absent salivary flow. Head and neck radiation was once considered the most common cause of dry mouth. In recent years medications have become the most common cause of dry mouth, with more than 400 drugs classified as xerogenic. ¹ Pharmacists need to be knowledgeable about the condition so they can provide appropriate education to patients and other health care providers on treatment options and methods for prevention. Although it is estimated that 20 percent of the elderly population are affected with dry mouth, it is not considered just a problem of aging. ^{2, 3} However the risk of dry mouth does appear to correlate with the number of medications a patient is taking, and elderly people often are taking multiple medications. ⁴ Studies also have shown dry mouth to be more prevalent in women. ⁴ Although dry mouth is a common complaint, a dentist or other healthcare provider may not typically discuss it during regular examinations. While some individuals find this condition a nuisance, lack of treatment or delayed intervention can lead to the development oral fungal infections, changes to the teeth and gums and a negative impact on one’s quality of life. According to the American Dental Association (ADA) Council on Scientific Affairs it is important that patients, pharmacists and healthcare providers have a better understanding of dry mouth risk factors, symptoms, complications, diagnosis, prevention and treatment options. ⁵ Prevention of complications includes aggressive evaluation of those at risk and proper oral hygiene techniques. Pharmacists play an important role in identifying patients at risk of medication-induced dry mouth and determining those who are candidates for self-treatment with nonprescription products and those who require dental referral.

TABLE 1

Signs and symptoms of dry mouth

Signs

Symptoms

Inflamed oral mucosa

Recurrent oral yeast infection

Salivary gland swelling

Chapped lips and tongue

Dry and pale cheeks

Sticky or dry feeling in the mouth, throat or tongue

Sore or burning throat

Trouble eating, speaking, swallowing or chewing

Altered sense of taste

Loss of appetite

Cracked lips

Frequent need to sip water, especially at night

Difficulty wearing dentures

Bad breath

Hoarse voice

Tooth hypersensitivity

Pharmacists should be aware of the various products available for treatment of dry mouth, as well as counseling on appropriate oral hygiene practices.

If you are a paid enrollee, there is no cost to participate in this lesson. The fee for participants who are not enrolled is $10.95.

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SALIVARY GLANDS

Saliva is a viscous, clear and watery fluid secreted from the salivary glands in the mouth. Salivary output is estimated at 1 to 1. 5 liters per day and can fluctuate throughout the day. ^{3, 4} Excess saliva then is recycled through swallowing. The three main glands that produce saliva are the parotid, submandibular and sublingual glands. The parotid is the largest gland and lies behind the jaw and below and in front of the ears. The smaller sublingual and submandibular glands lie deep in the floor of the mouth. Additionally there are hundreds of tiny salivary glands distributed throughout the mouth. Saliva is composed of 99 percent water in addition to proteins, enzymes and electrolytes. ⁴ Saliva contains two types of protein secretions including amylase, a digestive enzyme, and mucin, a lubricating secretion. Mucin also has been shown to aid in the trapping of microorganisms within the oral cavity. Lactoferrin, lysozyme and lactoperoxidase, glucose oxidase are just a few of the many

antimicrobial enzymes found in saliva. ⁴ Potassium, bicarbonate, sodium and chloride ions provide saliva with a buffering effect, controlling the pH at 6 to 7. 4. ⁴ These electrolytes also aid in enhancing the strength of tooth enamel and protecting the teeth from decay. Salivary flow is defined as being stimulated or unstimulated. The normal flow rate for stimulated and unstimulated, or resting, saliva is 1 to 2 mL/min and 0.3-0.5 mL/min, respectively. ⁴ Knowledge of these flow rates becomes important for diagnostic purposes. Saliva production is stimulated by the parasympathetic system, specifically the muscarinic M3 receptor and acetylcholine. Citric acid, chewing gum, use of lozenges and the taste and smell of food also trigger salivary flow. The sympathetic system (i.e., stress and anxiety) causes a thicker and decreased flow of saliva. Unstimulated saliva is saliva present in the mouth after 90 minutes of not drinking, eating or smoking. ⁴ Saliva has many functions, including antimicrobial activity, oral mucous membrane protection, digestion and enhancing of taste. It also provides lubrication necessary for speech, chewing and swallowing. Saliva aids in flushing food debris and bacteria away