Dry mouth, or xerostomia, is one problem in the oral cavity that poses a major problem for the elderly Xerostomia affects 3.3% of the American population, or about 8 million people. Many cases of xerostomia go undetected or unreported, resulting in underestimation of the problem.
With normal aging, changes typically occur in the oral cavity The epithelium becomes thinner, drier, and more susceptible to injury. Along with a modest decrease in taste sensitivity, the number and size of the taste buds diminish with age, especially along the anterior portion of the tongue. Some impairment in motor function typically affects chewing ability, and 50% of individuals are edentulous by age 65. This column addresses the factors, assessment, treatment, and nursing interventions involved in the problem of xerostomia.
The process of saliva production affects xerostomia. One of the many functions of saliva is the digestive action by which certain components of saliva digest nutrients. An antibacterial action controls the microbial population in the mouth. Saliva also provides lubrication and protection that aids in oral wound healing and maintains dentition. In addition, saliva neutralizes alkaline and acidic foods. It delivers the taste stimuli to the taste buds, helps maintain water balance in the body and has anticoagulation properties.
Saliva is produced by three major glands: the parotid, the submandibular, and the sublingual glands. Saliva is secreted, in response to neurotransmitter stimulation, at low basal levels throughout the day, but during mealtimes saliva secretion increases 50-fold.
Saliva production does not typically change as a function of normal aging. Though xerostomia is a common complaint among the elderly, there is no evidence that the aging process is responsible for drying of the mouth. Early studies demonstrated a decrease in saliva production with age; however, later research with better-controlled situations demonstrated no change in saliva production with normal aging (Baum, 1989). The parotid gland, responsible for the majority of saliva production, does not change with age. The sublingual and submandibular glands decrease saliva production with age, but it is not known how much this decrease contributes to a reduction in total available saliva.
When there is a diminished saliva supply, xerostomia or dry mouth occurs. Xerostomia may lead to various other problems that affect the quality of life for the elderly patient (Figure).
Causes of Xerostomia
Xerostomia has a variety of causes outside of normal aging. The most common causes of xerostomia include Sjogren's syndrome, radiation therapy, and medications.
The first, Sjogren's syndrome, is a disorder of the immune system in which white blood cell function is altered. White blood cell lymphocytes invade moisture-producing glands and cause them to stop production (Fox, 1986). The second, radiation therapy of the head and neck, also may cause changes in the salivary glands within the primary radiation beam range. The changes include degeneration of the acini and replacement with fibrous or fatty tissue. The actual extent of the degeneration depends on the amount of radiation received (Glass, 1984).
Lastly, more than 400 medications have the side effect of xerostomia. These medications are typically anticholinergic in nature, and include antihypertensive agents, diuretics, and antihistamines. Over-thecounter medications, especially products used for dieting, can cause a drying of the mouth (Glass, 1984).
In addition, a number of primary salivary gland diseases may result in reduced saliva production These diseases include sialadenitis (infection of the salivary glands), sialolith (obstruction of the salivary gland), aplasia (failure of the development of the tissue), excision of the salivary gland, and the most common, Sjogren's syndrome. Other causes of xerostomia include hormonal dysfunction, allergies, dehydration, blood loss anemia, mouth breathing, smoking, upper respiratory infections, menopause, diabetes, emotional changes, and vitamin A deficiency.
People who have xerostomia are especially predisposed to other illnesses. When assessing older individuals, the nurse should look closely at persons with an increased number of dental caries, thrush, indigestion (hiatal hernia), systemic infection, Sjögren's syndrome, or other connective tissue disease.
The evaluation of a complaint of xerostomia should be comprehensive and include a review not only of the gastrointestinal system, but also of the entire body. A history of dehydration, anemia, smoking, chronic cough, postnasal drip, mouth breathing, gum disease, and salivary gland disease or surgery should be evaluated. In addition, history of radiation therapy, vaginal dryness, laxative use, denture problems, dental disease, and weight gain or loss will be contributive.
The review of systems should be especially sensitive to a history of allergies, anemias, cancer, diabetes, epilepsy, gout, gastrointestinal disease, glaucoma/cataracts, hypertension, kidney disease, liver disease, lung disease (sarcoidosis), nervous disease, sinus problems, skin disease, tuberculosis, thyroid disease, arthritis, and connective tissue disease. All of these problems could be indicative of another underlying condition causing dry mouth, typically a connective tissue disease.
In addition to dryness, a symptom review may include difficulty with chewing, eating certain foods (ie, crackers), swallowing, and speaking. Patients may complain that their tongue sticks to the roof of the mouth. They may also report the need for constant fluids, and difficulty inserting or removing their dentures. Individuals with xerostomia often report that the dryness does not change with stimulation from food. They may experience frequent oral infections (candidiasis), altered taste, and marked dryness at night. Other complaints may include painful mouth or tongue, occasional choking or gagging sensation, dysgeusia (distorted tongue), burning tongue, adherence of food to buccal surfaces, and fissures of the tongue and lips. Other areas of the body are also frequently affected by dryness and may include changes in smell; dry, gritty, painful eyes; constipation; and a dry vagina.
An individual suffering with xerostomia typically exhibits dry, pale oral mucosa that has lost its glistening characteristic, a decreased sublingual pool, glossal illary atrophy (smooth, swollen tongue), or geographic tongue. Other physical signs of dryness include cheilitis (cracking of the corners of the mouth), poor dentition, gingival atrophy, salivary gland enlargement, and nilial infection.
Further Assessment and Evaluation
Confirmation of salivary gland dysfunction the use of objective tests should include salivary flow studies. One measure of salivary flow evaluates the response of salivary gland activity to mechanical stimuli, such as chewing on paraffin. The goal of this test is to increase salivary flow. Salivary flow may be measured by the patient expectorating saliva into a cup during a standard time interval. Another test that evaluates the presence of salivary glandular disease is salivary gland scintigraphy. This test is a functional exploration of the salivary glands using gamma rays emitted from an isotope; gland function is measured through the degree of uptake of isotope by the glands.
Possible Results of Xerostomia
Certain immunologic studies may indicate the presence of disease processes that may contribute to the xerostomia problem. These studies include a complete blood count with differential, antinuclear antibody, rheumatoid factor, Sjogren's syndrome A and B, and an erythrocyte sedimentation rate. In addition, salivary gland biopsy may be used to confirm a diagnosis of Sjogren's syndrome, AIDS, Hodgkin's disease, or normal aging.
There are a variety of treatment options for persons with xerostomia. Initially, treatment should be aimed at the reversible causes, such as the changing of medications and sleep positions, and corrections of ear/nose/throat conditions (such as a deviated septum or nasal obstruction). Palliative treatments usually include the use of artificial saliva, such as Mouthcoat, Xerolube, Salivant, or Oralube. The saliva substitutes are aqueous solutions containing electrolytes that simulate those found in saliva. Artificial saliva keeps the mouth moist, thereby reducing discomfort. Artificial saliva should be used if there is no response to mechanical or gustatory stimulation of the salivary glands. The saliva substitutes are available over the counter in most pharmacies.
Hard, sugarless candies and other acid-containing substances can be used to increase salivary flow. These substances can include citrus juice, sour ball candies, lemon drops, or hard-tart candy. Lemonglycerin swabs should not be used, since their acidic pH may lead to decalcification of the dentition (Poland, 1987).
Other useful interventions include the use of a humidifier to increase environmental moisture, mechanical stimuli through the use of foods requiring chewing (celery carrots), and sugarless chewing gum to stimulate salivary secretion. The avoidance of alcohol, carbonated beverages, and tobacco will further diminish dryness.
Certain health promotional activities are helpful for persons with xerostomia. Dental hygiene should include regular brushing, flossing, rinsing, and polishing of teeth and mouth. Using a fluoride preparation to coat the teeth daily may increase tooth strength. The use of a rinse to decrease bacteria in the mouth will reduce the potential for tooth decay. Lastly, the avoidance of certain foods that increase dryness and irritate the buccal mucosa - such as hot spices, cookies, and dry crackers - is recommended. Nurses should teach nursing assistants to use these interventions and to recommend dental checkups. Dental consultants to nursing homes should be asked to examine clients suspected of xerostomia.
Medications to improve salivary gland secretion are still experimental and are not generally available. The Salitron System, from Biotechnologies Inc., is a stimulation device that modifies nerve thresholds to induce salivation; this easyto-use device has been effective for many persons with xerostomia.
Other systems of the body may also be affected by dryness caused by systemic illness and may require interventions. Nutritional counseling should recommend water and foods with bulk and fiber to reduce constipation. Preventive ophthalmologic care consisting of protective eyewear and eye drops will increase eye comfort and reduce the risk of serious damage. To increase skin moisture, moisturizers and oils can be used. Hot baths/showers and soaps should be avoided, as they can further dry and irritate the skin. For vaginal dryness, the use of K-Y Jelly and estrogen creams are helpful.
Xerostomia is an uncomfortable condition that may cause other devastating problems affecting the body. A thorough evaluation of the dryness may indicate the presence of more serious underlying pathology, or a treatable condition. Thus the nurse can be helpful in deciding if the condition is treatable. There are many effective treatments available for persons with xerostomia, many of them nursing treatments.
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Possible Results of Xerostomia