Dry Mouth: Problems and Treatment for the Older Adult

1. Dry Mouth: Problems and Treatment for the Older Adult Clare Van Sant, RDH, BS

2. Learning Objectives At the completion of this module, participants will be able to: Visually identify Dry Mouth and explain its implications for oral health and systemic health Explain why controlling Dry Mouth is critical to older adults

3. Learning Objectives List the causes of Dry Mouth Describe ways to alleviate Dry Mouth Recommend ways to combat tooth decay due to Dry Mouth

4. Word Support Files The Glossary, References, Resources, Opening Activity, Evaluation Form, and Pre-Post Test with answers are found on a separate MS Word document.

5. Opening Activity Step 1: Have classmates open their mouths for examination. Step 2: Lift their tongues and look for salvia pooling in the floor of the mouth. Step 3: Focus on the inside of their cheeks and lips. Step 4: Examine the oral tissue to see if they are shiny and wet. See the Opening Activity in the MS Word document. See the Opening Activity in the MS Word document.

6. Dry Mouth or XerostomiaCan Affect Ability to eat, swallow, speak and smile Nourishment/food choices Ulcerations of oral tissues Tooth decay1,2 Dry Mouth, also known as xerostomia, can make it hard to eat, swallow, speak and even smile. Nourishment suffers as oral discomfort restricts food choices. Additionally, xerostomia promotes oral ulcerations, which can lead to systemic infections. Dry Mouth also causes rampant tooth decay. In fact, adults over age 65, currently have tooth decay at the same rate as teens due to xerostomia.1 Unfortunately, 65% of the salivary flow is typically lost before most people are even aware of oral dryness. In healthy mouths, the saliva glands produce 1.5 liters or 3 pints a day.2 The causes of Dry Mouth are well known and can be alleviated to improve oral comfort, oral health, overall health and quality of life.Dry Mouth, also known as xerostomia, can make it hard to eat, swallow, speak and even smile. Nourishment suffers as oral discomfort restricts food choices. Additionally, xerostomia promotes oral ulcerations, which can lead to systemic infections. Dry Mouth also causes rampant tooth decay. In fact, adults over age 65, currently have tooth decay at the same rate as teens due to xerostomia.1 Unfortunately, 65% of the salivary flow is typically lost before most people are even aware of oral dryness. In healthy mouths, the saliva glands produce 1.5 liters or 3 pints a day.2 The causes of Dry Mouth are well known and can be alleviated to improve oral comfort, oral health, overall health and quality of life.

7. Functions of Saliva in Healthy Mouths Protects teeth from acids and dilutes sugars. Protects the oral mucosa from injury and infection. Enables cheeks and tongue to slide easily over teeth in smiling, talking, chewing and swallowing. 1. Saliva coats the teeth so that any sugars put in the mouth are diluted and thus, less likely to cause tooth decay. The acids that result when sugar and oral bacteria combine are also diluted by saliva, making those acids less potent at decaying the teeth. During eating, the flow of saliva increases. It flows more abundantly for up to 20 minutes after completing eating. This increase in salivary flow helps facilitate chewing and helps protect the teeth while sugars and acidic fruits or drinks are in the mouth. 2. Saliva moisturizes the soft tissues of the interior of the mouth such as gums, lining of the cheeks, tongue, roof and floor of the mouth, and throat. It makes all those soft tissues less prone to injury. When the oral tissues are moisturized, they are less likely to be traumatized or injured by sharp or crunchy foods. The natural antibiotics in saliva kill germs that can cause infections in the mouth. These oral infections can potentially travel through the blood stream to infect other areas of the body. 3. The saliva lubricates the inside of the mouth, making the lips, cheeks and tongue slide easily across the teeth. Think about a time when your mouth was dry from nervousness or when you had a cold. Remember how it was more difficult just to form words. 1. Saliva coats the teeth so that any sugars put in the mouth are diluted and thus, less likely to cause tooth decay. The acids that result when sugar and oral bacteria combine are also diluted by saliva, making those acids less potent at decaying the teeth. During eating, the flow of saliva increases. It flows more abundantly for up to 20 minutes after completing eating. This increase in salivary flow helps facilitate chewing and helps protect the teeth while sugars and acidic fruits or drinks are in the mouth. 2. Saliva moisturizes the soft tissues of the interior of the mouth such as gums, lining of the cheeks, tongue, roof and floor of the mouth, and throat. It makes all those soft tissues less prone to injury. When the oral tissues are moisturized, they are less likely to be traumatized or injured by sharp or crunchy foods. The natural antibiotics in saliva kill germs that can cause infections in the mouth. These oral infections can potentially travel through the blood stream to infect other areas of the body. 3. The saliva lubricates the inside of the mouth, making the lips, cheeks and tongue slide easily across the teeth. Think about a time when your mouth was dry from nervousness or when you had a cold. Remember how it was more difficult just to form words.

8. Functions of Saliva in Healthy Mouths Moistens food, making it easier to move around in the mouth. Fights oral infections with antibiotics and antimicrobials. 4. Saliva adds to the food we eat, helps liquefy it, and makes it easier to maneuver in the mouth. Lack of saliva makes chewing far more difficult. Think of a time when your mouth was dry and you tried to eat. Remember how it took more effort. If you had a cold, you already felt lousy. Imagine if you were on chemotherapy and, in addition to all your other battles, your mouth was dry and now just chewing your food took monumental effort. 5. Saliva contains natural antibiotics and antimicrobials. Oral infections are kept at bay by these germ-fighters. By controlling oral infections, potential systemic infections that could be introduced into the body through the oral cavity are lessened. 4. Saliva adds to the food we eat, helps liquefy it, and makes it easier to maneuver in the mouth. Lack of saliva makes chewing far more difficult. Think of a time when your mouth was dry and you tried to eat. Remember how it took more effort. If you had a cold, you already felt lousy. Imagine if you were on chemotherapy and, in addition to all your other battles, your mouth was dry and now just chewing your food took monumental effort. 5. Saliva contains natural antibiotics and antimicrobials. Oral infections are kept at bay by these germ-fighters. By controlling oral infections, potential systemic infections that could be introduced into the body through the oral cavity are lessened.

9. With Reduced, Thickened or No Saliva Rampant tooth decay Mucosa more easily injured Oral and systemic infections more common Increased difficulty in chewing, swallowing, speaking and smiling Dry Mouth causes rampant tooth decay. Remember, adults over age 65 currently have tooth decay at the same rate as teens due to xerostomia.1 Additionally, Dry Mouth makes the oral tissues more vulnerable to ulceration, which can expose the entire body to infection.Dry Mouth causes rampant tooth decay. Remember, adults over age 65 currently have tooth decay at the same rate as teens due to xerostomia.1 Additionally, Dry Mouth makes the oral tissues more vulnerable to ulceration, which can expose the entire body to infection.

10. Causes of Dry Mouth Common Drugs: Antidepressants Diuretics Hypertension medications Decongestants Antihistamines Acid reflux medications Inhalants3 Over 600 medications have Dry Mouth as a side effect, including eight of the top 20 most prescribed drugs.3Over 600 medications have Dry Mouth as a side effect, including eight of the top 20 most prescribed drugs.3

11. Causes of Dry Mouth Chemotherapy4 Radiation to Head & Neck Diabetes Sjogren�s syndrome Salivary duct blockage Mouth breathing Stress Besides medications, there are many other causes of Dry Mouth: Approximately, forty percent of all chemotherapeutic treatments have oral side effects, including painful Dry Mouth.4 Radiation to the head and neck region permanently disables salivary glands. Dry Mouth can be a lifelong after effect. If at all possible, radiation treatments to the head or neck area should be given with lead shields protecting salivary glands. Diabetes and Sjogren�s Syndrome cause Dry Mouth. Blocked salivary ducts can be addressed surgically to restore saliva flow. Mouth breathing dries the oral tissues; the gums are characteristically red and inflamed. We all know the uncomfortable feeling of a dry mouth when nervous or stressed.Besides medications, there are many other causes of Dry Mouth: Approximately, forty percent of all chemotherapeutic treatments have oral side effects, including painful Dry Mouth.4 Radiation to the head and neck region permanently disables salivary glands. Dry Mouth can be a lifelong after effect. If at all possible, radiation treatments to the head or neck area should be given with lead shields protecting salivary glands. Diabetes and Sjogren�s Syndrome cause Dry Mouth. Blocked salivary ducts can be addressed surgically to restore saliva flow. Mouth breathing dries the oral tissues; the gums are characteristically red and inflamed. We all know the uncomfortable feeling of a dry mouth when nervous or stressed.

12. Appearance of Xerostomic Oral Tissues Dry Pale Transparent Notice the lack of shiny wetness in these photographs.5Notice the lack of shiny wetness in these photographs.5

13. Linear Gingival Erythema With reduced saliva coating the oral tissues, the mouth turns more acidic and vulnerable to infections. As a result, the gums often become fiery red just along the gum line. This is called Linear Gingival Erythema and is evident, even in ethnic groups, where there is pigmentation coloring the gums. With reduced saliva coating the oral tissues, the mouth turns more acidic and vulnerable to infections. As a result, the gums often become fiery red just along the gum line. This is called Linear Gingival Erythema and is evident, even in ethnic groups, where there is pigmentation coloring the gums.

14. Features of Dry Tongue Possible burning sensation or soreness Inflamed Dry and tough Fissured Atrophic papillae, causing tongue to appear pebbly Denuded, if severe, causing tongue to appear smooth5

15. Features of Dry Tongue.5Features of Dry Tongue.5

16. Tips to Alleviate Dry Mouth Drink frequent sips of water Suck ice chips Use sugar-free gum, mints and hard candies Avoid alcoholic drinks Moisturize lips Sleep with a room vaporizer To alleviate Dry Mouth, carry water everywhere! Suck on ice chips. Sugar-free gum, mints and hard candies stimulate saliva. Alcoholic drinks are drying to oral tissues. Keep dry lips lubricated. Room vaporizers reduce dryness in the air.To alleviate Dry Mouth, carry water everywhere! Suck on ice chips. Sugar-free gum, mints and hard candies stimulate saliva. Alcoholic drinks are drying to oral tissues. Keep dry lips lubricated. Room vaporizers reduce dryness in the air.

17. Tips to Alleviate Dry Mouth Rinse at least twice daily with a half teaspoon baking soda dissolved in one cup of warm water. Ask pharmacist for salivary substitutes, available behind pharmacy counter without prescription. Try mouthwash, toothpaste and chewing gum, found in the dental aisle, made especially for Dry Mouth.6 Rinsing with a solution of baking soda twice a day neutralizes the acidity of a dry mouth. Some people may need to swish with it up to 6 times a day. For rinsing throughout the day, a half teaspoon of baking soda may be dissolved in a quart of water instead of a cup of water. This simple, low-cost rinse can dramatically reduce redness, inflammation and discomfort from Dry Mouth. There are also saliva substitutes, such as oral gels, rinses and convenient sprays that are available behind the pharmacy counter without prescription. Other products marked especially for Dry Mouth can be found on the dental aisle. Additionally, dentists and physicians can prescribe medications that protect the flow of saliva, such as pilocarpine and cevimeline, HCl.6 In cancer cases, these prescription medications should be considered as early as possible, once the cancer diagnosis is made and the treatment plan introduced.Rinsing with a solution of baking soda twice a day neutralizes the acidity of a dry mouth. Some people may need to swish with it up to 6 times a day. For rinsing throughout the day, a half teaspoon of baking soda may be dissolved in a quart of water instead of a cup of water. This simple, low-cost rinse can dramatically reduce redness, inflammation and discomfort from Dry Mouth. There are also saliva substitutes, such as oral gels, rinses and convenient sprays that are available behind the pharmacy counter without prescription. Other products marked especially for Dry Mouth can be found on the dental aisle. Additionally, dentists and physicians can prescribe medications that protect the flow of saliva, such as pilocarpine and cevimeline, HCl.6 In cancer cases, these prescription medications should be considered as early as possible, once the cancer diagnosis is made and the treatment plan introduced.

18. Tips to Alleviate Dry Mouth Choose Foods That Are: Soft Moist Easy to chew Thinned or softened with liquids Lukewarm Not spicy, sour or acidic Not crunchy or sharp For more comfortable eating, choose foods that are soft, moist and easy to chew, thinned or softened with liquids such as broth, gravy, sauces, yogurt or milk. Choose lukewarm food, not very hot or icy cold, not spicy, sour or acidic, not crunchy or sharp as these can cut or scrape oral tissues.For more comfortable eating, choose foods that are soft, moist and easy to chew, thinned or softened with liquids such as broth, gravy, sauces, yogurt or milk. Choose lukewarm food, not very hot or icy cold, not spicy, sour or acidic, not crunchy or sharp as these can cut or scrape oral tissues.

19. Tips to Alleviate Dry Mouth Take small bites Chew slowly Sip liquids while eating Take small bites, chew slowly and sip, sip, sip.Take small bites, chew slowly and sip, sip, sip.

20. Tips to Combat Rampant Caries After eating, brush teeth with soft brush and small dab of fluoride toothpaste. Floss gently, yet thoroughly, between teeth once daily. Apply 1.1% neutral sodium fluoride gel daily, as directed. A clean mouth is essential to fighting tooth decay. For strengthening teeth against decay, 1.1% sodium fluoride is available by prescription from a dentist and should be considered for anyone with Dry Mouth. A clean mouth is essential to fighting tooth decay. For strengthening teeth against decay, 1.1% sodium fluoride is available by prescription from a dentist and should be considered for anyone with Dry Mouth.

21. Tips to Combat Rampant Caries Chew gum sweetened with xylitol 3-5 times a day for 3-5 minutes. Avoid lemon glycerin swabs and lemon-flavored candy. Avoid nystatin oral rinses which contain sugar and promote rampant tooth decay. Consider alternate anti-fungal regimens.7 Xylitol is an artificial sweetener that remineralizes tooth structures, thus fighting tooth decay. Therapeutic dosage of xylitol: The gum should be chewed 3-5 times a day for 3-5 minutes. It is preferable that xylitol be the only sweetner, but it should be at least the first sweetener listed under ingredients. Avoid lemon glycerin swabs and lemon-flavored candy because they make the mouth more acidic and thus, cause tooth decay. Nystatin rinses or lozenges are anti-fungals which can cause rampant tooth decay when held in the mouth of someone with Dry Mouth and natural teeth, even if the teeth are crowned.7Xylitol is an artificial sweetener that remineralizes tooth structures, thus fighting tooth decay. Therapeutic dosage of xylitol: The gum should be chewed 3-5 times a day for 3-5 minutes. It is preferable that xylitol be the only sweetner, but it should be at least the first sweetener listed under ingredients. Avoid lemon glycerin swabs and lemon-flavored candy because they make the mouth more acidic and thus, cause tooth decay. Nystatin rinses or lozenges are anti-fungals which can cause rampant tooth decay when held in the mouth of someone with Dry Mouth and natural teeth, even if the teeth are crowned.7

22. Dry Mouth: Problems and Treatment Care of the Mouth During Cancer Therapy Dry Mouth is often a debilitating side effect of cancer therapies, even interrupting therapy sometimes. This unit looks at how the mouth can be affected by chemotherapeutics and radiation therapy and how oral side effects can be addressed to minimize disruptions to cancer treatment.Dry Mouth is often a debilitating side effect of cancer therapies, even interrupting therapy sometimes. This unit looks at how the mouth can be affected by chemotherapeutics and radiation therapy and how oral side effects can be addressed to minimize disruptions to cancer treatment.

23. Care of the Mouth During Cancer Therapy  Oral Mucosa During Cancer Therapy: Friable Ulcerated Necrosed Raw Painful Radiation therapy and many chemotherapy drugs can cause dramatic changes in the mouth. The soft, moist lining of the mouth, called mucosa, often becomes more friable, thus, ulcerating very easily. The mucosa may necrose or die and slough off, leaving the mouth raw and painful. Radiation therapy and many chemotherapy drugs can cause dramatic changes in the mouth. The soft, moist lining of the mouth, called mucosa, often becomes more friable, thus, ulcerating very easily. The mucosa may necrose or die and slough off, leaving the mouth raw and painful.

24. Care of the Mouth During Cancer Therapy Saliva: Protects teeth Protects oral tissues Can diminish during cancer therapy Can dry up permanently Saliva, essential for protecting the teeth and oral tissues, can diminish, even completely dry up as a result of chemotherapy or radiation therapy. After chemo, the salivary flow usually returns. The loss of saliva with head or neck radiation therapy is permanent. This is why shielding the salivary glands during head and neck radiation, if at all possible, is so important.Saliva, essential for protecting the teeth and oral tissues, can diminish, even completely dry up as a result of chemotherapy or radiation therapy. After chemo, the salivary flow usually returns. The loss of saliva with head or neck radiation therapy is permanent. This is why shielding the salivary glands during head and neck radiation, if at all possible, is so important.

25. Care of the Mouth During Cancer Treatment Oral Side Effects of Cancer Therapy: Dry Mouth Ulcerated oral tissues Painful to speak, smile, chew and swallow Difficult to keep nourished Infections enter body through open oral sores These changes in the mucosa and saliva cause Dry Mouth and oral ulcerations, which make it very difficult to move the mouth to speak, smile and make other facial expressions. Additionally, it is more challenging to keep nourished when it hurts to chew and swallow. These oral side effects of chemotherapy and radiation treatment can allow infections to enter the body through the open sores of the mouth. Since resisting infection and keeping well nourished, while fighting cancer, are of the utmost importance, the following tips help to keep the mouth more intact and comfortable while undergoing cancer treatment.These changes in the mucosa and saliva cause Dry Mouth and oral ulcerations, which make it very difficult to move the mouth to speak, smile and make other facial expressions. Additionally, it is more challenging to keep nourished when it hurts to chew and swallow. These oral side effects of chemotherapy and radiation treatment can allow infections to enter the body through the open sores of the mouth. Since resisting infection and keeping well nourished, while fighting cancer, are of the utmost importance, the following tips help to keep the mouth more intact and comfortable while undergoing cancer treatment.

26. Care of the Mouth During Cancer Treatment Seek dental evaluation as soon as cancer is diagnosed. Check mouth daily and report new or worsening sores, pain, dryness to nurse or dental professional. Chemotherapy and radiation patients MUST have any necessary dental work completed BEFORE cancer therapy begins. Therefore, it is imperative that a dentist evaluate the oral condition as soon as cancer is diagnosed. Besides performing any necessary dental procedures before the start of therapy, the dental team can offer support to the cancer patient to keep both teeth and oral tissues more comfortable and intact during therapy. Involving the dental team helps to reduce interruptions to the therapy schedule due to oral problems. All cancer patients need to be advised to consult their dental professionals as early as possible once cancer is diagnosed. The cancer team needs to follow up on this important pre-requisite for cancer therapy. Ideally, a dentist and a dental hygienist should be part of every cancer team.Chemotherapy and radiation patients MUST have any necessary dental work completed BEFORE cancer therapy begins. Therefore, it is imperative that a dentist evaluate the oral condition as soon as cancer is diagnosed. Besides performing any necessary dental procedures before the start of therapy, the dental team can offer support to the cancer patient to keep both teeth and oral tissues more comfortable and intact during therapy. Involving the dental team helps to reduce interruptions to the therapy schedule due to oral problems. All cancer patients need to be advised to consult their dental professionals as early as possible once cancer is diagnosed. The cancer team needs to follow up on this important pre-requisite for cancer therapy. Ideally, a dentist and a dental hygienist should be part of every cancer team.

27. Care of the Mouth During Cancer Treatment Keep the mouth as clean as possible by brushing teeth, gums and tongue with: Soft or extra soft toothbrush Warm water Small dab of fluoride toothpaste Change toothbrush every 2-3 months

28. Care of the Mouth During Cancer Treatment Avoid sore areas Floss once daily, thoroughly, yet gently. Avoid sore areas. Floss once daily, thoroughly, yet gently. Avoid sore areas.

29. Care of the Mouth During Cancer Treatment Avoid traumatizing gums with: Toothpicks Worn toothbrushes Ill �fitting dentures Broken fillings Broken teeth

30. Care of the Mouth During Cancer Treatment Avoid old, worn toothbrushes Worn toothbrush bristles are actually sharp on the ends and can cut gum tissues. Toothbrushes should be changed at least every three months. Worn toothbrush bristles are actually sharp on the ends and can cut gum tissues. Toothbrushes should be changed at least every three months.

31. Care of the Mouth During Cancer Treatment Avoid traumatizing gums with dentures that no longer fit well. This is common with weight loss due to cancer and therapy. Avoid traumatizing gums with dentures that no longer fit well. This is common with weight loss due to cancer and therapy.

32. Care of the Mouth During Cancer Treatment Repair decayed, broken or rough teeth and broken fillings Broken, decayed, broken or rough teeth can cut the oral tissues. Broken or rough fillings can traumatize the oral tissues and need to be replaced or smoothed by the dentist before cancer therapy begins. Broken, decayed, broken or rough teeth can cut the oral tissues. Broken or rough fillings can traumatize the oral tissues and need to be replaced or smoothed by the dentist before cancer therapy begins.

33. Care of the Mouth During Cancer Treatment Choose food that are: Soft, moist, easy to chew Lukewarm, neither hot nor very cold Thinned or softened with liquids Not spicy, sour or acidic Not crunchy or sharp Take small bites Chew slowly Sip while eating When thinning foods, use some liquids such as broth, gravy, sauces, yogurt and milk. Crunchy or sharp foods can scrape oral tissues, resulting in injury. Sip, sip, sip.When thinning foods, use some liquids such as broth, gravy, sauces, yogurt and milk. Crunchy or sharp foods can scrape oral tissues, resulting in injury. Sip, sip, sip.

34. Care of the Mouth During Cancer Treatment �Magic Mouthwash� includes: Magnesium hydroxide Diphenhydramine solution Lidocaine Relieves pain when eating. Swish 10 minutes before meals. In extreme cases of pain, morphine may be prescribed. Dentists and physicians can prescribe �Magic Mouthwash� to relieve pain while eating. It usually contains some variation of magnesium hydroxide/diphenhydramine solution and lidocaine. Swish with this mouthwash for 10 minutes before meals. In extreme cases, morphine may be prescribed. Dentists and physicians can prescribe �Magic Mouthwash� to relieve pain while eating. It usually contains some variation of magnesium hydroxide/diphenhydramine solution and lidocaine. Swish with this mouthwash for 10 minutes before meals. In extreme cases, morphine may be prescribed.

35. Care of the Mouth During Cancer Treatment Avoid irritating oral tissues with tobacco. Avoid irritating oral tissues with alcoholic drinks. Avoid alcohol in mouthwash.

36. Care of the Mouth During Cancer Treatment Rinse two-six times daily with half a teaspoon of baking soda dissolved in one quart water. If thrush becomes a problem, ask dentist or physician about sugar-free anti-fungal medications, rinses or lozenges. Rinse two to six (2-6) times daily for one minute with half teaspoon baking soda dissolved in one quart water. This simple, but important, solution neutralizes oral acids. Be sure to use after any vomiting episodes since stomach acids can erode tooth enamel. If thrush, a whitish fungal infection common in the mouth during chemo, becomes a problem, ask dentist or physician about anti-fungal medications. If possible, avoid nystatin rinses and lozenges, which contain a heavy concentration of sugar and promote rampant tooth decay. Rinse two to six (2-6) times daily for one minute with half teaspoon baking soda dissolved in one quart water. This simple, but important, solution neutralizes oral acids. Be sure to use after any vomiting episodes since stomach acids can erode tooth enamel. If thrush, a whitish fungal infection common in the mouth during chemo, becomes a problem, ask dentist or physician about anti-fungal medications. If possible, avoid nystatin rinses and lozenges, which contain a heavy concentration of sugar and promote rampant tooth decay.

37. BIOGRAPHY Clare Van Sant, RHD, BS, has been bringing onsite dental hygiene care into nursing homes since April 2002. She conducts oral health in-services for groups such as nursing home staff, seniors centers and Hospice volunteers. She received her BS in Dental Hygiene from the Medical College of Georgia in 1975. Her experiences include working as a public health dental hygienist, clinical periodontal therapist and community oral health educator.