Hyposalivatory drug use, whole stimulated salivary flow, and mouth dryness in older, long-term care residents

A Pilot Study to Assess the Feasibility of Real-Time Teledentistry in Residential Aged Care Facilities

BACKGROUND/OBJECTIVES

Unmet oral health needs of residents in residential aged care facilities (RACFs) arise due to the unique challenges of assessing oral health statuses and maintaining oral healthcare in RACFs. This pilot study assessed the feasibility of using real-time teledentistry under the guidance of a dentist to train RACF staff to undertake an oral health assessment.

METHODS

An oral health assessment of residents was first conducted by RACF staff at two Queensland, Australia RACFs using the Oral Health Assessment Tool, with an intra-oral camera connected to a laptop, through videoconferencing, under the guidance of a dentist. A survey recorded the views of RACF staff on the acceptability of the teledentistry method. The quality of the images obtained through the camera was assessed by the dentist. Finally, cost-effectiveness was calculated between teledentistry and traditional face-to-face assessments.

RESULTS

Sixteen residents (mean age 79.3 ± 8.68 years) and eight staff (mean age 33.3 ± 6.16 years) participated in this study. Both RACF staff and residents found that the real-time teledentistry set-up was user-friendly, while the dentist rated the quality of the images as acceptable for diagnostic purposes. Real-time teledentistry was more cost-effective than bringing a dentist on-site, while taking the RACF residents to an off-site dental office for examination was the most expensive approach.

CONCLUSIONS

Real-time teledentistry is feasible and cost-effective, and it is an acceptable alternative to a face-to-face clinical exam for oral health assessment in RACFs. This approach could be used in RACFs where wireless internet connectivity is available.

Therapeutic Recommendations for the Management of Older Adult Patients with Sjögren's Syndrome

Primary Sjögren's syndrome (SjS) is a systemic autoimmune disease most commonly diagnosed in middle-aged women. Although the disease can occur at all ages, it is diagnosed between 30 and 60 years of age in two-thirds of patients. In more than 20% of cases, the people are older than 65 years. In this review, we focus on the therapeutic management of primary SjS in older patients, following the recently published 2020 European League Against Rheumatism (EULAR) recommendations for the management of the disease with topical and systemic therapies. These recommendations are applicable to all patients with primary SjS regardless of age at diagnosis, although the therapeutic management in older patients requires additional considerations. Older patients are more likely to have pulmonary, liver, kidney, or heart-related comorbidities (even cognitive disturbances); caution is required when most drugs are used, including muscarinic agents, systemic corticosteroids and synthetic immunosuppressants. It is also important to monitor the use of eye drops containing steroids due to the increased risk of developing cataracts, a frequent ocular complication in the older population. In contrast, the majority of drugs that can be used topically (pilocarpine rinses, eye drops containing topical non-steroidal anti-inflammatory drugs (NSAIDs) or cyclosporine A, topical dermal formulations of NSAIDs) have shown an acceptable safety profile in older patients, as well as rituximab. A rigorous evaluation of the medical history of older patients is essential when drugs included in the EULAR guidelines are prescribed, with special attention to factors frequently related to ageing, such as polypharmacy, the existence of organ-specific comorbidities, or the enhanced susceptibility to infections.

Dry Eyes, Ocular Lubricants, and Use of Systemic Medications Known or Suspected to Cause Dry Eyes in Residents of Aged Care Services

Ocular issues are common, burdensome, and under-researched among residents of aged care services. This study aims to investigate the prevalence of dry eyes or use of ocular lubricants among residents, and the possible association with systemic medications known or suspected to cause dry eyes. A cross-sectional study of 383 residents of six aged care services in South Australia was conducted. Data were extracted from participants' medical histories, medication charts, and validated assessments. The main exposure was systemic medications known to cause, contribute to, or aggravate dry eyes. The primary outcome was documented dry eyes or regular administration of ocular lubricants. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between systemic medications and dry eyes/use of ocular lubricants. Dry eyes were documented for 53 (13.8%) residents and 98 (25.6%) residents were administered ocular lubricants. Overall, 116 (30.3%) residents had documented dry eyes/used ocular lubricants. Of these, half (n = 58) were taking a medication known to cause, contribute to, or aggravate dry eyes. Taking one or more medications listed as known to cause dry eyes was associated with having dry eyes/use of ocular lubricants (OR 1.83, 95% CI 1.15-2.94). In sub-analyses, no individual medication was associated with dry eyes/use of ocular lubricants. Dry eyes and use of ocular lubricants are common in residential aged care. Our hypothesis generating findings suggest the need for further research into the clinical significance of systemic medications as a possible cause of dry eyes.

Meta-analysis: Risk of dry mouth with second generation antidepressants

OBJECTIVE

The goal of this meta-analysis was to quantify the risk of dry mouth associated with commonly prescribed antidepressant agents and examine the potential implications of medication class, dose, and pharmacodynamics and dose on risk of treatment-induced dry mouth.

DATA SOURCES AND STUDY SELECTION

A PubMed search was conducted to identify double-blind, randomized, placebo-controlled trials examining the efficacy and tolerability of second generation antidepressant medications for adults with depressive disorders, anxiety disorders, and OCD.

DATA EXTRACTION

A random-effects meta-analysis was used to quantify the pooled risk ratio of treatment-emergent dry mouth with second generation antidepressants compared to placebo. Stratified subgroup analysis and meta-regression was utilized to further examine the effects antidepressant agent, class, dosage, indication, and receptor affinity profile on the measured risk of dry mouth.

RESULTS

99 trials involving 20,868 adults. SNRIs (Relative Risk (RR)=2.24, 95% Confidence Interval (CI): 1.95-2.58, z=11.2, p<0.001) were associated with a significantly greater risk of dry mouth (test for subgroup differences χ²=7.6, df=1; p=0.006) compared to placebo than SSRIs (RR=1.65, 95% CI: 1.39-1.95, z=5.8, p<0.001). There was a significant difference found in the risk of dry mouth between diagnostic indications within the SNRI class (test for subgroup differences χ²=9.63, df=1; p=0.002). Anxiety diagnoses (RR=2.78, 95% CI: 2.29-3.38, z=10.32, p<0.001) were associated with a greater risk of dry mouth compared to depression (RR=1.80, 95% CI: 1.48-2.18, z=5.85, p<0.001). Decreased affinity for Alpha-1 (PE=0.18, 95% CI: 0.07-0.28, z=3.26, p=0.001) and Alpha-2 (PE=0.49, 95% CI: 0.22-0.75, z=3.64, p<0.001) receptors and SERT (PE=0.07, 95% CI: 0.01-0.14, z=2.10, p<0.05) was significantly associated with increased risk of dry mouth.

CONCLUSIONS

The current meta-analysis suggests that SSRIs, SNRIs, and atypical antidepressants are all associated with varying degrees of increased risk of dry mouth. SNRIs were associated with a significantly greater risk of dry mouth compared to SSRIs.

Xerostomia and salivary hypofunction in vulnerable elders: prevalence and etiology

OBJECTIVE

The goal of this article is to review existing research on the prevalence and etiology of dry mouth in the vulnerable elders and identify knowledge gaps.

STUDY DESIGN

Vulnerable elders (VE) are persons aged >65 years who have any or all of the following: limited mobility, limited resources, or complex health status. A systematic search was conducted of PubMed sources from 1989 to May 2010. Evidence was evaluated on the prevalence and etiology of xerostomia and salivary gland hypofunction (SGH) in VE.

RESULTS

The search identified 1,422 publications. The inclusion/exclusion criteria yielded 348 articles, 80 of which are cited herein.

CONCLUSIONS

Research has showed a high prevalence of xerostomia and SGH in VE. Common etiologies include medications, poor general health, female gender, and age. Gaps still exist in the evaluation of dry mouth in VE. Nonetheless, oral dryness will remain an important health issue as life expectancy increases.

Associations between oral and ocular dryness, labial and whole salivary flow rates, systemic diseases and medications in a sample of older people

OBJECTIVE

To investigate the associations between age, gender, systemic diseases, medications, labial and whole salivary flow rates and oral and ocular dryness in older people.

METHODS

Symptoms of oral and ocular dryness, systemic diseases, medications (coded according to the Anatomical therapeutic chemical (ATC) classification system), tobacco and alcohol consumption were registered, and unstimulated labial (LS) and unstimulated (UWS) and chewing-stimulated (SWS) whole salivary flow rates were measured in 668 randomly selected community-dwelling elderly aged 65-95.

RESULTS

Presence of oral (12%) and ocular (11%) dryness was positively correlated. Oral dryness was associated with low UWS, SWS and LS, and ocular dryness with low UWS and SWS. Oral and ocular dryness was related to female gender, but not to age. Only four persons in the healthy and nonmedicated subgroups reported oral and ocular dryness. The numbers of diseases and medications were higher in the older age groups and associated with oral and ocular dryness, low UWS, SWS and LS. On average, women were slightly older, reported more oral and ocular dryness and had lower UWS, SWS, LS and higher numbers of diseases and medications. High prevalence and odds ratios for oral dryness were associated with metabolic, respiratory and neurological diseases and intake of thyroid hormones, respiratory agents (primarily glucocorticoids), psycholeptics and/or psychoanaleptics, antineoplastics, proton pump inhibitors, antidiabetics, loop diuretics, antispasmodics, quinine and bisphosphonates. Ocular dryness was especially associated with neurological diseases and intake of psycholeptics and/or psychoanaleptics. Intake of magnesium hydroxide, antithrombotics, cardiac agents, thiazides, beta-blockers, calcium channel blockers, ACE inhibitors/angiotensin II antagonists, statins, glucosamine, paracetamol/opioids, ophthalmologicals and certain combination therapies was related to oral and ocular dryness.

CONCLUSIONS

In older people, oral and ocular dryness are associated with low salivary flow rates, specific as well as high number of diseases and medications, but neither with age and gender per se nor with tobacco and alcohol consumption. New detailed information concerning associations between medications and oral and ocular dryness has been obtained using the ATC classification system.

Efficacy of a new oral lubricant solution in the management of psychotropic drug-induced xerostomia: a randomized controlled trial

OBJECTIVE

Xerostomia is a subjective sensation of mouth dryness often occurring as an unwanted effect of psychotropic drugs.

METHODS

The clinical efficacy and acceptability of a new oxygenated glycerol triester (OGT) oral spray (1 or 2 sprays up to 4 times daily) in the treatment of xerostomia was compared with those of a commercially available artificial saliva substitute (ASS [Saliveze]) in a 2-week, open-labeled, randomized, parallel-group study. Clinical assessment of xerostomia included evaluation of mouth dryness by means of a 10-cm-long visual analog scale, objective blinded assessment of the oral tissue condition by a dental hygienist by means of a 4-point ordinal scale, and subjective patient-based assessment of dry mouth symptoms by means of dichotomous responses to a questionnaire. [Day 14 - baseline] patient-based mouth dryness score was the primary end point.

RESULTS

Seventy-four patients (41 women and 33 men, 44 +/- 15 years) undergoing long-term psychotropic drug treatment were consecutively enrolled. At day 14, OGT resulted in better efficacy than ASS in mouth dryness score (mean difference, 1.2 +/- 0.4; P = 0.006), speech difficulties (mean difference, 1.2 +/- 0.4; P = 0.005), taste (mean difference, 1.1 +/- 0.4; P = 0.02), and overall mouth condition (mean difference, 1.4 +/- 0.9; P = 0.005). Taste of OGT was better than that of ASS (mean difference, 1.4 +/- 0.6; P = 0.04), as was OGT acceptability (mean difference, 1.4 +/- 0.9; P = 0.005).

CONCLUSION

Oxygenated glycerol triester lubricant oral spray was superior to a commercially available ASS in improving xerostomia and overall condition of the oral tissue.

Factors associated with self-reported halitosis (SRH) and perceived taste disturbance (PTD) in elderly

The aim of this study was to estimate the prevalence of self-reported halitosis (SRH) and perceived taste disturbance (PTD) and analyze their association with age, gender, subjective oral dryness, burning mouth, tongue coating, number of teeth remaining, and type of dentures and wear duration in healthy elderly. Subjects who neither reported systemic disorders nor medication use were included in the study. The participants of this study were 254 healthy subjects, 116 males (mean age: 63.2+/-7.2 years) and 138 females (mean age: 61.9+/-6.8 years), all aged 55 years and above. A self-administered structured questionnaire on SRH and PTD was given to the participants. Each subject underwent a comprehensive dental examination by one of the examiners. The number of carious teeth, number of restorations, type of dentures (fixed-partial, removable-partial or complete dentures) and wear duration, and tongue coating status were recorded. Associations of the categorical background variables (age, gender, smoking status, tooth brushing frequency) with SRH and PTD were examined using the chi(2)-test. Spearman's rho correlation coefficient was used to analyze the relationship between taste disturbance and SRH with relevant variables (p<0.05). The prevalence of SRH was 28.3% and the prevalence of PTD was 8.3%. Use of the toothbrush less than once daily was the factor most strongly associated with SRH. Of the individuals with SRH, 73.6% reported subjective oral dryness (p<0.001) and 9.7% had burning mouth (p=0.008). Of the individuals with PTD, 71.4% reported subjective oral dryness (p=0.003) and 14.3% had burning mouth (p=0.019). Age (p<0.05), denture type (p<0.001), tongue coating (p<0.001), frequency of tooth brushing (p<0.000 for SRH and p<0.05 for PTD) were significantly associated with SRH and PTD. Educational level of the participants was significantly different for SRH (p<0.05). Gender was not found to be associated with either SRH or PTD (p>0.05). We concluded that the factors most strongly associated with SRH and PTD were subjective oral dryness, tongue coating, inadequate oral hygiene practice and partial and/or complete denture wear. Other factors with significant associations included older age and lower education levels. Smoking was found to be associated with SRH.

Impact of dry mouth and hyposalivation on oral health-related quality of life of elderly Japanese

OBJECTIVE

To determine the association of hyposalivation and the perception of dry mouth with oral health-related quality of life for independently living elderly.

STUDY DESIGN

The study sample consisted of 287 participants (mean age, 66.1 years) at a Senior Citizen educational system. Stimulated salivary flow rates during chewing were measured. The OHIP-14 to measure the impact of oral conditions on health-related quality of life was used, and summary OHIP-14 scores combining the response codes for the 14 items were analyzed.

RESULTS

A logistic regression analysis showed that a higher OHIP-14 score indicating a poorer quality of life was related to fewer residual teeth, perception of dry mouth on eating (OR: 4.01, P = .012) and hyposalivation (OR: 2.71, P = .006).

CONCLUSION

It is suggested that both dry mouth and hyposalivation are important problems influencing the quality of life in independently living, relatively healthy elderly Japanese.

Prevalence of xerostomia in population-based samples: a systematic review

The consequences of xerostomia on oral health have been studied for decades; however, the actual prevalence of this disorder on the general population remains controversial. The purpose of this systematic review was to determine the prevalence of xerostomia in population-based samples. Electronic databases were screened for relevant articles and reference lists of pertinent articles were also hand-searched. Thirteen articles meeting the final inclusion criteria were identified. Based on the definition of xerostomia used in this review, only publications including a subjective diagnosis of the disorder were included. All of the self-reported diagnoses were achieved through a questionnaire either by mail, telephone, interview or self-administered by the patient. There was a variation across papers regarding number and content of the questions as well as guidelines for the diagnosis of xerostomia (i.e. answer yes to one or more than one question). The prevalence of xerostomia in the selected articles ranged from 0.9% to 64.8%. The majority of these studies were performed in Scandinavia. In 9 of the articles, the studied samples were 50 years and older. None of the studies evaluated the prevalence xerostomia among individuals younger than 18 years. Based on these observations, it can be concluded that there is a need for population-based studies on prevalence of xerostomia in regions other than Scandinavia. A standardized protocol to diagnose xerostomia needs to be developed. Patient-perceived treatment needs and impact on quality of life should be included to have a complete picture of public health implications of the disease.

Impact of dry mouth conditions on oral health-related quality of life in older people

OBJECTIVE

The aim of the present study was to evaluate the impact of dry mouth conditions on oral health-related quality of life in frail old people, residents at community care centers. Further, reliability and validity of a visual analogue scale (VAS) for dry mouth symptoms were determined within the study cohort.

BACKGROUND

In old people functional, social and psychological impacts of oral conditions are associated with an overall sense of well being and general health. Subjective dry mouth and reduced saliva flow are common disorders in old people caused by disease and medication. Thus, dry mouth conditions may be determinants for compromised oral health-related quality of life in old people.

METHOD

In total, 50 old people living at service homes for the old people were asked to answer questionnaires on subjective dry mouth (VAS) and Oral Health Impact Profile (OHIP14) for oral health-related quality of life. Saliva flow was estimated by absorbing saliva into a pre-weighed cotton roll.

RESULTS

The final study cohort comprised 41 old people (aged 83-91 years). Significant associations were identified between both objective and subjective dry mouth and overall or specific aspects of oral health-related quality of life.

CONCLUSION

Dry mouth (objective and subjective) is significantly associated with oral health-related quality of life strengthening the value of monitoring dry mouth conditions in the care of frail old people.

Impact of dry mouth on oral symptoms and function in removable denture wearers in Japan

OBJECTIVE

The purpose of this study was to determine the association of dry mouth with oral symptoms and function, such as denture instability, discomfort, soreness in denture-bearing tissue, and dissatisfaction with chewing, tasting, or speaking in removable denture wearers.

STUDY DESIGN

The subjects were 493 removable denture wearers with a mean age of 67.3 years. Perception of oral dryness was measured by a questionnaire. A multiple logistic regression analysis was used to determine the effect of the dry mouth on oral symptoms and function after controlling for age and gender.

RESULTS

Oral dryness during eating was related to dissatisfaction with chewing (odds ratio, 10.5; P < .001) and speaking (odds ratio, 3.5; P < .05) and overall dissatisfaction (odds ratio, 6.3; P < .01) in complete denture wearers. Feeling of dry mouth was likely to be associated with soreness in denture-bearing tissues in both complete and removable partial denture wearers.

CONCLUSIONS

There was a significant association of the perception of dry mouth among a group of denture wearers with oral symptoms and function.

Salivary hypofunction and xerostomia: diagnosis and treatment

Salivary gland hypofunction and complaints of xerostomia are common in elderly patients, irrespective of their living situation. Medication use is frequently related to dry mouth symptoms and reductions in salivary flow rates. Patients with reduced salivary flow are at increased risk for caries, oral fungal infections, swallowing problems, and diminished or altered taste. Oral health care providers should institute aggressive preventive measures and recommend palliative care for patients with significant reduction in salivary gland function. The systemic agents pilocarpine and cevimeline may help selected patients. Selective use of fluoride-releasing restorative materials and conservative treatment plans are recommended for this patient group.

Prevalence of dental caries in an adult population with mental disabilities in Spain

The objective of this study was to analyze the prevalence of dental caries and the possible influence of extraoral factors in a group of adults with a mild to moderate degree of developmental delay. A total of 166 subjects ranging in age from 20 to 40 years were examined. All subjects were institutionalized, and 70.4% (n = 117) participated in a preventive program designed by the educators of the center. This consisted of weekly fluoride mouthrinses (0.2%) and control of dental plaque by toothbrushing with a fluoride toothpaste. The mean DMFT index for the whole sample was 5.97. Subjects in the oldest age group had the highest DMFT index and the lowest filled component. There were no significant differences in the DMFT index and its components between the subjects who received a weekly fluoride mouthrinse (n = 117) and those who did not (n = 49). Comparison of subjects who had cerebral palsy, Down Syndrome, and idiopathic developmental delay (n = 157) found a significantly lower DMFT index (p < 0.05) in the persons with Down Syndrome compared with the other special-needs groups. Other factors which could influence the results-such as fluoride use, oral hygiene, and administration of benzodiazepines-were also analyzed. An analysis of the results revealed a moderately high prevalence of caries in the whole sample that was lower than that in a national survey. This could be attributed to strict dietary control of sugar in the study population.

Perception of dry mouth in a sample of community-dwelling older adults in Japan

The purpose of this study was to examine the prevalence of perceived dry mouth among a group of independently-living elderly persons in Japan, and to determine its association with general disease, medication, and dental status, as well as its effect on oral function. The study population consisted of participants of the Senior Citizens' College. The subjective sensations of oral dryness on waking and while eating a meal were measured by a questionnaire. The number of usable questionnaires was 1003 or 77.9%. The mean age of the subjects was 66.3 +/- 4.2 years, and 53.0% were male. More than one-third (37.8%) of the subjects reported oral dryness on waking. Only 9.1% of them noticed a subjective feeling of dry mouth during eating. Persons who had at least one of these symptoms made up 41.0%. A multiple stepwise logistic regression analysis indicated the following results: Perception of dry mouth on waking was more frequent among males (p < 0.001), persons who had a low BMI (p < 0.05), and those taking two or more prescribed drugs (p < 0.01). Sensation of dry mouth when eating was more frequent among subjects with a low BMI (p < 0.001) and those who wore a denture in the maxillary arch (p < 0.05). Perception of dry mouth when eating was associated with self-assessed chewing ability (p < 0.01) and dissatisfaction with speaking clearly (p < 0.05), as well as dental status. However, dissatisfaction with tasting a meal had a significant relationship with the reports of mouth dryness on waking (p < 0.01). Our findings suggest that a substantially higher percentage of persons have the perception of dry mouth on waking than when eating, which was associated with medications, being male, and having a low BMI. This perception may influence oral function, especially the reported dissatisfaction with tasting foods.

Xerostomia and hyposalivation

Dry mouth must not be considered a trivial problem in the population, since it constitutes a phenomenon with many aspects relative to oral function as well as quality of life. Up until today, no global consensus has been reached with regard to the terminology of dry mouth, creating a substantial problem for research, education, diagnosis, and therapy. In this report, salivary gland hypofunction has been selected as the overarching term for subjective symptoms and objective signs of dry mouth. Its different aspects--xerostomia, hyposalivation, and altered saliva composition--are reviewed with respect to prevalence, diagnosis, and etiology. It is concluded that these aspects of salivary gland hypofunction are separate entities, which in many respects are interrelated, constituting not merely a dental but also a medical and social concern.

Acquired salivary dysfunction. Drugs and radiation

When considering the effects of drugs on salivary glands, a distinction should be drawn between the complaint of oral dryness (xerostomia), a symptom, and measurable secretory hypofunction, a sign. In general, the symptom of xerostomia is often not accompanied by objective reductions in salivary output, and xerostomia is not a reliable indicator of secretory hypofunction. Whereas therapeutic pharmaceutical side effects represent the most prominent cause of xerostomia, with over 500 drugs associated with this symptom, only a small number of drugs have been demonstrated to reduce salivary output substantially. There are examples in which drugs with a high prevalence of xerostomia complaints do not affect secretory function. The mechanisms responsible for this discrepancy between subjective and objective findings have not been fully identified. It is hypothesized that alterations in systemic or mucosal hydration may play a role. Of the drugs with true salivary hypofunctional actions, most have direct anticholinergic properties. In almost all cases, the salivary effects of pharmaceuticals are not permanent, and function returns to pretreatment levels when the medication is stopped. By contrast, the effects of irradiation on the salivary glands are permanent when exposures exceed 50 Gy. About 40,000 individuals per year receive irradiation that involves the salivary glands (by external beam or internal sources--radon implants and 1311) for treatment of cancers of the head and neck region. Although these radiation effects have been recognized as a significant clinical problem for more than 80 years, the specific mechanisms responsible for radiation-induced salivary gland dysfunction are still not understood. With the exception of studies documenting the secretory functional deficits following head and neck irradiation, limited studies have been done in humans. The majority of experimental work has been done in rodents. A variety of mechanisms, including mitotic and interphase cell death, direct DNA damage or effects of secondary metabolites, damage to progenitor cells, or altered gene expression, have all been proposed to explain the salivary epithelial cell death observed. Recent experimental studies with models of radiation-induced salivary damage in rats and a human salivary cell line suggest that the small percentage of surviving epithelial cells are capable of performing functions such as signal transduction and ion transport normally. Apoptotic cell death following irradiation has not been a prominent feature in these model systems. The effects of head and neck radiation on the salivary glands and oral cavity continue to present multiple significant clinical problems both during and after radiotherapy. In recent years, there has been some progress in minimizing these effects through more careful shielding and pretreatment planning. Additionally, there are preliminary results from a clinical trial suggesting that the use of a secretagogue, pilocarpine HCl, given during the course of radiotherapy, may reduce the secretory hypofunctional effects. A multicenter trial is now underway to test this hypothesis. There is still a real need to develop more effective treatments for this condition.

A reference guide to drugs and dry mouth--2nd edition

Xerostomia (dry mouth) is an uncomfortable and potentially harmful oral symptom which is usually caused by a decrease in the secretion rate of saliva (salivary gland hypofunction, or SGH). It is more prevalent in the elderly population, primarily due to their increased use of drugs and their susceptibility to disease. Many drugs and drug classes have been linked to xerostomia; the xerogenic effect increases when many drugs are taken concurrently. This Reference Guide to Drugs and Dry Mouth is designed to allow the reader to rapidly identify those pharmacologic agents which have the capacity to induce xerostomia and SGH. Xerogenic drugs can be found in 42 drug categories and 56 sub-categories. A guide to the management of drug-induced SGH and xerostomia is also provided.

Prevalence of perceived symptoms of dry mouth in an adult Swedish population--relation to age, sex and pharmacotherapy

The aim of the study was to evaluate the prevalence of subjective perception of dry mouth in an adult population and to determine the prevalence of pharmacotherapy in this population. An additional aim was to assess a possible co-morbidity between symptoms of dry mouth and continuing pharmacotherapy. Four-thousand-two-hundred persons were selected at random from the national census register of the adult population of the southern part of the province of Halland, Sweden. The sample was stratified according to age and sex, and 300 men and an equal number of women aged 20, 30, 40, 50, 60, 70 and 80, were included. A newly developed questionnaire was mailed to each individual. In addition to questions about subjective perception of dry mouth, the subjects were asked to report on present diseases and continuing pharmacotherapy. Three-thousand-three-hundred and thirteen (80.5%) evaluable questionnaires were returned. The estimated prevalence of xerostomia in the population was 21.3% and 27.3% for men and women, respectively. This difference between the sexes was statistically significant. In non-medicated subjects, women tended to report a higher prevalence of xerostomia compared with men, 18.8% vs. 14.6%, and also among medicated subjects the estimated prevalence of dry mouth was higher for women than for men, 32.5% vs. 28.4%. There was a strong association between xerostomia and increasing age and also between xerostomia and continuing pharmacotherapy. The average prevalence of dry mouth among medicated and non-medicated subjects was 32.1% and 16.9%, respectively, the difference being statistically significant. There was also a strong association between xerostomia and the number of medications. In a logistic regression, the probability of reporting mouth dryness was significantly greater in older subjects and in women, and the probability increased with the number of medications taken. In conclusion, this epidemiological survey of an adult population has demonstrated that women, independent of age, do report a higher prevalence of xerostomia than men and that the symptom of dry mouth is strongly associated with age and pharmacotherapy. It is, however, not possible to discriminate between disease and pharmacotherapy as causal factors.

Associations between self-assessed masticatory ability and some general health factors in a Swedish population

OBJECTIVES

The aims of this study were 1) to describe changes in self-assessed masticatory ability over a 14 year period (1975-89); and 2) to describe associations between self-assessed masticatory ability and age, dental state and some other background factors in a sample of the Swedish population in 1988/89.

DESIGN

The Swedish National Central Bureau of Statistics investigates annually the living conditions of the Swedish population by means of interviews by trained persons. The data were analysed by means of stepwise logistic regression and calculation of adjusted relative risks.

SUBJECTS

In the investigation in 1988/89, 12,901 people above 16 years of age participated and the response rate was 80%.

RESULTS

In comparison between the investigations, the prevalence of reported impairment was lower in 1988/89 than in 1975 and 1980/81. Prevalence of reported impairment of chewing ability increased with ageing from 2% in young adults (16-34 years old) to 44% in older elderly (> 85 years old). In most age groups, edentulous people reported the highest prevalence, and dentate people the lowest. Relative risks for impaired masticatory ability, independent of age, gender and dental state, were higher for people in rural areas, with low income and living single, as well as for those with skeletal, gastrointestinal, psychiatric and tumour diseases. In the elderly, results from the logistic regression showed that some disability and psychosocial factors were also associated with masticatory ability.

CONCLUSIONS

The results indicated that there was a group of elderly people who reported several functional and health problems including impaired masticatory ability.

Relationship of medical status, medications, and salivary flow rates in adults of different ages

Multiple systemic disorders and medications have been reported to cause xerostomia or salivary gland hypofunction. The purpose of this study was to evaluate the relationship among systemic disorders, medications, and salivary flow rates. Sixty-three ambulatory dental patients aged 23 to 82 years were randomly selected. The nature, duration, and number of systemic disorders and medications were documented. Repeated measurements of unstimulated whole, chewing-stimulated whole, acid-stimulated parotid, and candy-stimulated parotid salivary flow rates were obtained. Data were analyzed with the Wilcoxon rank-sum test, nonparametric multivariate analysis of variance, and Fisher's exact test. For persons with systemic disorders who were taking medication, all salivary flow rates were significantly (p = 0.03 - 0.001) lower than the flow rates in healthy persons. Among persons with at least one systemic disorder who were taking medication, those who had been taking medication for longer than 2 years had significantly lower unstimulated whole saliva (p = 0.002), chewing-stimulated whole saliva (p = 0.0004), and candy-stimulated parotid saliva (p = 0.02) flow rates than those who had been taking medication for 1 to 2 years. The number of systemic disorders significantly (p = 0.02) and negatively affected the acid-stimulated parotid salivary rates. The prevalence of salivary hypofunction determined on the basis of unstimulated whole saliva and acid-stimulated parotid saliva was significantly higher (p = < 0.001, p = 0.007) in the those persons with systemic disorders and taking medications. The results suggest that salivary secretion is affected by the number of systemic disorders and duration of the potentially xerogenic medications.

Impact of medical and life-style factors on number of teeth in 68-year-old men in southern Sweden

The aim of the present study was to investigate the impact of general health and life-style factors on the number of remaining teeth in 68-year-old men living in the city of Malmö, Sweden. The study included 483 men (participation rate, 78%). Poor self-assessed health, frequent medical attendance, diabetes, and oral dryness were related to fewer remaining teeth. Number of teeth was negatively correlated to concentrations of triglycerides and alkaline phosphatases in serum and to glucose in blood but positively correlated to serum urea. Various dietary variables including consumption of sucrose-containing products and nutritional quality were not related either to number of teeth or to prevalence of edentulousness. Smoking and high consumption of coffee or alcohol were associated with fewer remaining teeth. Multiple logistic regression analyses showed that social class, frequency of dental attendance, smoking, and serum concentrations of triglycerides and urea had an independent effect on number of teeth.

Xerostomia in older adults: a longitudinal study

Although xerostomia in older adults has received substantial research attention, there have been few longitudinal studies of non-patient populations. Consequently, little is known about the incidence or course of this condition among this group. This paper reports the results of a longitudinal study designed to address these issues. In 1989, data on xerostomia were collected from 907 randomly-selected community dwelling adults aged 50 years and over. Three years later, 611 (71% of those presumed to be alive) were followed-up and data on xerostomia collected again. At baseline, 15.5% of these 611 subjects reported xerostomia, while at follow-up this had risen to 29.5%. The majority of the latter (115/180) were incident cases, reporting xerostomia only at follow-up, while the remainder were chronic cases, reporting xerostomia at both baseline and follow-up. A crude estimate of the three-year incidence rate was 22.5%. In a logistic regression analysis, three baseline variables were associated with incidence; older subjects, those with one or more chronic medical conditions and those reporting their general health as poor were more likely to develop xerostomia. In a similar analysis, age was the only variable associated with chronicity, with older subjects more likely to be chronic cases. The data also suggest that the onset of xerostomia was associated with an increase in other oral symptoms and problems with eating, communication and social interaction.

Salivary function and hypertension: a review of the literature and a case report

Limited evidence suggests a relationship between the use of antihypertensive medications and reduced salivary function. This article provides a review of the literature concerning the relationship between hypertension, hypertensive therapy and salivary function. A case report is presented to illustrate changes in salivary function in response to different types of antihypertensive medications.

Three-year root caries incidence and risk modeling in older adults in North Carolina

OBJECTIVES

The purposes of this study were to describe the incidence of root caries and to identify its risk factors in a representative sample of older adults.

METHODS

Root caries incidence was estimated and multivariate risk assessment models were developed to identify predictors for root caries in a three-year follow-up study of 234 black and 218 white noninstitutionalized adults aged 65 and older residing in North Carolina.

RESULTS

During the observation period, 29 percent of blacks developed root caries, compared to 39 percent of whites (P < .05). The mean net DFS increment per person was 0.55 +/- 0.13 root surfaces for blacks vs 0.80 +/- 0.21 for whites (P > .32). Multivariate logistic regression analysis indicated that blacks wearing a partial denture, having some root fragments, having an average gingival recession > or = 2 mm, and being free of P. intermedia were at greater risk for developing new root caries. The model for whites showed that retired people with their most severe gingival recession > or = 4 mm, an average probing pocket depth > or = 2 mm, and taking antihistamines were more likely to develop new lesions.

CONCLUSIONS

These findings suggest that older blacks had less risk of root caries than whites, and in both groups indicators of poor periodontal status increased the risk of root caries.

Stimulated parotid salivary flow rates in normotensive, hypertensive, and hydrochlorothiazide-medicated

Stimulated parotid salivary flow rates were compared in elderly normotensive, hypertensive, and controlled hypertensive African-Americans, the latter group taking hydrochlorothiazide (HCTZ). The normotensive group consisted of 15 healthy unmedicated subjects with systolic blood pressures of less than 150 mm Hg and diastolic pressures less than 90 mm Hg. The hypertensive group consisted of 10 unmedicated subjects with systolic pressures greater than 160 mm Hg and diastolic pressures greater than 100 mm Hg. The controlled hypertensive group consisted of 20 subjects taking HCTZ (50 mg, daily) with controlled blood pressures similar to the normotensive control group. Stimulated parotid salivary samples were collected from each subject. A 2% citrate solution applied to the dorsum of the tongue was used for stimulation. The results showed no significant differences in stimulated parotid flow rates between normotensive and uncontrolled hypertensive subjects. However, the medicated, controlled hypertensive subjects had a significant reduction of stimulated parotid salivary flow rates compared to both the normotensive and hypertensive groups.

Comparison of stimulated parotid salivary gland flow rates in normotensive and hypertensive persons

Although hypertension is a prevalent condition among the elderly, little is known with respect to the influence of hypertension on oral health and function. Therefore a study was conducted that compared stimulated parotid salivary flow rates in elderly persons (65 years and older) from two diverse populations who are normotensive, mild, and severe hypertensive. The normotensive group consisted of 45 healthy subjects with systolic blood pressures of less than 140 mm Hg and diastolic pressures less than 90 mm Hg. The mildly hypertensive group consisted of 14 otherwise healthy subjects with either systolic pressures greater than 140 mm Hg or diastolic pressures greater than 90 mm Hg. The severely hypertensive group consisted of 10 otherwise healthy subjects with either systolic pressures greater than 180 mm Hg and/or diastolic pressures greater than 100 mm Hg. All three groups were not taking any prescription or nonprescription medications. Samples of 2% citrate-stimulated parotid saliva were collected from each subject. The results showed no significant differences in stimulated parotid flow between normotensive, mildly hypertensive, and severely hypertensive subjects. These results suggest that hypertension per se has no influence on stimulated parotid salivary gland flow rates in otherwise healthy, elderly unmedicated white and African-American persons.

Salivary gland dysfunction: causes, symptoms, treatment

The three most common known causes of salivary gland dysfunction are medication usage, radiation therapy and Sjogren's syndrome. Current therapeutic options to treat salivary dysfunction are limited. Clinical considerations as well as the outlook for individuals experiencing salivary dysfunction are discussed.

Mouth dryness as reported by older Floridians

Thirty-nine percent of 600 community-dwelling older Floridians (mean age of 78 yr) reported having mouth dryness. Seventy-nine percent of respondents reported at least one medical condition, 57% were taking at least one prescribed or over-the-counter medication, and 33% were taking at least one potentially xerostomic medication. Reported mouth dryness was highly associated with the number of potentially xerostomic medications. After stratification by medication usage, age, diabetes, arthritis, perceived medical health, and dependence in physical functioning were significantly associated with mouth dryness. Persons with dry mouth were also more likely to have reported dental symptoms, signs of dental disease, sensory changes, and other oral symptoms. Ten percent of those who reported mouth dryness also said that their mouths felt dry when eating a meal, 10% said that they had difficulties swallowing foods, and 15% of persons with dry mouth also said that the amount of saliva in their mouths was too little. Sixty-five percent of persons with dry mouth reported doing one or more dryness-related behaviors. These results suggest that the prevalence of xerostomia was high, and the impact of dry mouth on individuals' daily behaviors was significant.

A characterization of major salivary gland flow rates in the presence of medications and systemic diseases

The purpose of this study was to characterize the effects of medications and systemic diseases on major salivary gland flow rates. Unstimulated and 2% citrate-stimulated parotid and submandibular salivas were collected from 293 subjects of the oral physiology component of the Baltimore Longitudinal Study of Aging. The influence of the number of medications and diseases on salivary flow rates was determined by separate one-way ANOVA tests. There was an overall decrease in both parotid and submandibular flow rates with increasing numbers of medications and systemic diseases. However, this was significant (p < 0.05) only for unstimulated submandibular flow rates (with increasing numbers of systemic diseases) and stimulated submandibular flow rates (with increasing numbers of systemic diseases and medications). Unstimulated flow rates rapidly approached zero with increasing numbers of medications and diseases. These results suggest that the submandibular gland may be more sensitive to physiologic permutations than the parotid gland. In addition, individuals being treated for multiple systemic diseases and taking numerous medications may be more susceptible to salivary hypofunction.

Subjective reports of oral dryness in an older adult population

In this study of an older adult population almost one-fifth reported oral dryness. It was the most common of 22 oral symptoms and complaints. In a logistic regression analysis of predictors of oral dryness three variables had significant independent effects: income, taking prescribed medications and experiencing a stressful life change within the previous 6 months. Subjects with oral dryness had more decayed crown surfaces than those without but there was no association with decayed root surfaces. Nor were there any significant associations between reports of oral dryness and a number of indicators of periodontal health. Those with dryness were more likely to report other oral symptoms such as unpleasant taste, a burning sensation in the tongue and other parts of the mouth and pain from dentures. They were also more likely to report problems chewing food, problems with eating and communication and were more likely to be dissatisfied with their oral health. Given its prevalence and effects, oral dryness constitutes an important health issue among older adults.

Xerostomia: the missing diagnosis?

Xerostomia is a distressing condition which may be associated with a number of specific diseases, iatrogenically induced following the administration of drugs or radiotherapy, or the result of inflammatory processes affecting salivary gland tissue. In this article epidemiological background is briefly reviewed and aetiological conditions associated with xerostomic states are summarized. The oral sequelae of xerostomia are discussed and approaches to diagnosis demonstrated. Treatment of xerostomia is basically supportive and the main elements are presented.