From mildly relaxed to
"I thought I was asleep"
You can be as relaxed as you wish.
Trying to help a patient with a dry mouth can be frustrating.
I agree with all of what Hardy said.
The commercial OTC "artificial salivas" are mostly useless as:
1. They do not replace any of the functions of saliva; i.e. pH
buffering, remineralizing, lubrication, food bolus formation, etc.
2. Whatever symptomatic relief they offer disappears as soon
as the patient swallows.
3. They are expensive ($10-25 per bottle).
4. Patient acceptance is poor, with poor compliance due to bad
taste; in spite of a little flavouring agent, they still taste like someone spit
in your mouth (please doctors, try them before you suggest them to patients!).
Far better is the Biotene products:
http://www.laclede.com/
Distributed in Canada by Bolton:
http://www.bdmcan.com/product-info.html
Our Sjogrens and radiation patients particularly like the Oral Balance gel: they rub it on their tongues before they go to bed to keep from waking up with their tongue stuck to the roof of their mouth (a common complaint) and on their front teeth at the beginning of the day to keep from sticking to their lips.
Vaseline and other petroleum based products are useless for this, and actually cause more cracking and peeling by leaching under the surface mucosa and lifting it off. This is why you occasionally get patients in that say they are "addicted" to Chapstik or vaseline on their lips. These products cause cracking and peeling, which the patients treat by putting on more Chapstik / vaseline, which causes more cracking and peeling, and on and on.
Water based products for the lips (Blistex, Lypsol, KY jelly) don't have this problem. The patient has to apply it to their lips more often because it is easier to lick off, but they don't have the cracking / peeling problems of petroleum based products. The KY jelly is cheapest, and now they have a small purse / backpack size packaging which is handy. Just encourage your male patients to throw away the package insert...
Stay on top of the oral candidiasis that always seems to happen with xerostomic patients. The nystatin swish 'n swallow that we were all taught in school is mostly useless. Compliance is poor (YOU try to swish something in your mouth for a minute, by the clock) and all the formulations in Canada are 50% sucrose (and guess what these bugs eat!!), so a recurrence is almost guaranteed. Instead we tend to go systemic (ketoconazole 200mg bid X 7 days as long as the patient doesn't have any hepatic problems like cirrhosis or HepB or C carrier, or fluconazole 100mg hs X 7 days if they do. Fluconazole is $6-10 per pill, so we don't start with it, keto is cheap.).
We prescribe a lot of Salagen for our patients. Likely this renal patient has hypertension, however, which is a contraindication. The problem with people trying Salagen, you have to explain to your patient that it will take two or three months of faithful taking before you will even know if it will work. The side effects are annoying (sweating, GI upset), but are dose related, and the patients' bodies tend to get used to them, if you slowly build up the dosage while you are waiting for the beneficial effects to take hold.
We go for the maximum salivary effect at 30mg a day for every patient. Even our "little old ladies". The trick is to slowing build up the dose so that the side effects are not overwhelming.
We generally will start a patient off on 5mg tid for a week or two, then bump it up to 5mg qid for a week or two. As long as the patient can handle the side effects (and has it together enough to manage a complicated regimen), we then have them double their morning dose for a week or two and then double their afternoon dose. By this time they are on the maximum dose (30mg/d) with manageable side effects. If one of the "steps" causes uncomfortable side effects, we bump them back down to the previous dose for another week or two, and then try to move up their dose again.
I have taken the liberty of attaching a handout I use for a lecture I give on
managing a dry mouth ("Desperately Seeking Saliva"). It is in
Word97 format.
If it doesn't come through the listserve, anyone can send me a note at:
trey.petty@crha-health.ab.ca
and I can send it to you directly.
Trey Petty
Foothills Medical Centre / Tom Baker Cancer Centre
Calgary
Management of a Dry Mouth
(Xerostomia)Trey L. Petty, DDS, FAGD, FADI
Foothills Medical Centre, Oral Medicine
403/ 670-2401 trey.petty@crha-health.ab.ca
Common causes of xerostomia:
Temporary Causes:
Physiological stress
Drugs or medications with anticholinergic effect
Dehydration: negative fluid states
Excessive use of diuretics
Trauma; infection in salivary glands, parotitis
Neurosis and depression; emotional and anxiety states
Persistent Causes:
Primary Sjogrens syndrome: dry mouth, dry eyes
Secondary Sjogrens syndrome (CT disease: RhA, SLE)
Diabetes mellitus; polyuria state
Therapeutic radiation with fields involving the salivary glands
Sarcoidosis, amyloidosis
Viral infections: HIV, HSV, EBV, CMV
Absent or malformed salivary glands
Anti-depressants are the most likely iatrogenic cause of a dry mouth.
Common anti-depressants with the greatest anti-cholinergic potency:
amitriptyline (Elavil®)
imipramine (Tofranil®)
doxepin (Sinequan®) Dry Mouth Questions:
lithium; secondary diuretic effect 1. Do you sip liquids to aid in swallowing dry foods?
2. Does your mouth feel dry when eating a meal?
Management by dose reduction and / or substitution: 3.Do you have difficulties swallowing any foods?
protriptyline (Triptil®) 4. Does the amount of saliva in your mouth seem to be
desipramine (Norpramin®) too little, or too much, or don’t you notice?
fluoxetine (Prozac®) Fox, et al. JADA, 1987.
Management of Xerostomia:
Keep mouth moist:
Frequent sips of fluids; club soda
Sugarless gum & mints
Biotene products - available over the counter (800/ 667-3770, www.laclede.com)
Artificial saliva products are available, but many complain of objectionable taste.
Water-based moisturizing products on lips: e.g. Blistex, K-Y Jelly, Dermabase
Avoid petroleum-based lip products eventually cause more peeling and cracking:
e.g. Vaseline, Chapstik, Lypsol
Humidifier in sleeping and / or work area.
Emphasize good oral hygiene; consider topical fluoride treatment, chlorhexidine rinses or toothpastes.
Avoid tobacco, alcohol, caffeine, salt which all have a drying effect. Careful with most mouthwashes which contain high concentrations of alcohol.
Gentle dentistry:
Careful impressions: use only alginate, polyvinyl siloxane or silicone; not ZOE
Partial dentures: minimize tissue contact
Complete dentures: retention should be optimized; consider building in a fluid reservoir in the base design
Salagen (pilocarpine) 5 mg bid first week,
(FMC / TBCC protocol): then 5 mg tid second week,
then 5 mg qid third week,
then double first dose fourth week,
then double third dose fifth week, so that
daily protocol: 10 mg - 5 mg - 10 mg - 5 mg
Incremental increase in dosage to max. of 30 mg / day titrated to optimal outcome; rate of increase dependent on side effects (sweating, urinary frequency, chills, flushing, GI upset)
Burning Mouth Syndrome
Trey L. Petty, DDS, FAGD, FADI
403/ 670-2401
Foothills Medical Centre, Oral Medicine
trey.petty@crha-health.ab.ca
Differential diagnosis includes:
xerostomia
candidiasis
chronic infection
reflux gastritis
medication side effects
blood dyscrasias
nutritional deficiencies
allergic and inflammatory disorders
psychogenic factors including factitious lesions (i.e. habit induced)
Typical work-up includes:
CBC and differential, glucose, iron, ferritin, folic acid and B12
Typically no abnormalities are found.
Classic therapy would suggest one or a combination of: topical anesthetics (viscous lidocaine or benadryl elixir), antidepressants (e.g. clonazepam; should try at least one month before outcome is known).
Capsaicin compounds (from use in chemotherapy patients: Berger A., Yale Science Update, Fall 1994):
Edentulous patients can use the Zostrix 0.025% cream as a liner in their denture (tid - qid).
The problem is finding a friendly pharmacy that likes to formulate their own compounds.
Following are the formulations we most typically use: (patients can often make these up themselves)
Capsaicin Candy: (problem - can have sharp edges which can be irritating)
Dissolve 2 C. brown sugar in 1/4 molasses, 1/2 C. butter, 2 Tbs. water and 2 Tbs. vinegar over low heat in a heavy pan. Boil gently, stirring frequently until the hard-crack stage (300 degrees F, the temperature at which a spoonful of candy separates into hard and brittle threads when dropped into cold water). Add 1/2 tsp. cayenne pepper. Drop candy from a teaspoon onto a buttered slab or foil to form patties. Makes about one pound.
Capsaicin Taffy: (softer, but more difficult to make)
Combine 1 C. Sugar, 3/4 C. light corn syrup, 2/3 C. Water, 1 Tbs. Cornstarch, 2 Tbs butter or margarine, 1 tsp. salt and cook over medium heat, stirring constantly to 256 degrees F (candy thermometer) or to the hard ball stage. Remove from heat. Stir in flavoring (e.g. 2 tsp vanilla) and 1/2 tsp. cayenne pepper. When cool enough to handle, pull taffy. When stiff, pull into strips, cut into pieces and wrap.
Make clear to the patient that they will experience an initial burn. Usually, the burn of the capsaicin is no more intense than the pain they already experience and it will subside shortly after they begin using the cream or candy regularly. If they get a positive effect, this does not seem to cure, rather a decrease in symptomology is found which typically needs re-treatment.
Management of Oral Candidiasis
Trey L. Petty, DDS, FAGD, FADI
403/ 670-2401
Foothills Medical Centre, Oral Medicine
trey.petty@crha-health.ab.ca
Types of oral candidiasis
(a.k.a. "thrush", moniliasis, "yeast" infection):Pseudomembraneous candidiasis
Atrophic candidiasis
Angular cheilitis
Typical therapy (oral "swish and swallow"):
Rx: Nystatin oral suspension (e.g. Mycostatin®) 100,000 IU/ml
5 ml. p.o. swish for 1 minute then swallow t.i.d. X 10 d
Problems:
assumes conscious, compliant patient
contains 50% sucrose
must remove dentures
Rx: Nystatin cream 100,000 IU/gm
Apply t.i.d. X 10 d
Indicated for angular cheilitis or under denture
Systemic therapy:
Rx: Ketoconazole 200mg
1 tab p.o. b.i.d. X 10 d
hepato-toxic:
Caution with history of alcohol-abuse, cirrhosis, HBV, HCV
Contraindicated in patients taking cyclosporin (transplants, etc.) or Prepulsid
Rx: Fluconazole (Diflucan®) 100mg
1 tab at h.s. X 10 d
very expensive
Note: With any therapy, symptoms will disappear within 2-3 days, however, because the Candidal hyphae grow into the surface of the tissue, prolonged therapy (10 days) is required to prevent immediate recurrence.
Candidal hyphae can also grow into the surface of denture acrylic. To avoid immediate re-infection, patients should soak dentures in diluted vinegar solution (1:1 with water) every evening at h.s., not bleach.
EXAMPLES OF SOME MEDICATIONS WHICH CAUSE A DRY MOUTH:
Brand Name:
Generic Name:
Anorexiants:
Adipex-P, Fastin, Ionamin, Zantryl phentermine
Anorex SR, Adipost, Bontril PDM phendimetrazine
Mazanor, Sanorex mazindol
Pondimin, Fen-Phen fenfluramine
Tenuate, Tepanil, Ten-Tab diethylpropion
Anti-acne:
Accutane isotretinoin
Anti-anxiety:
Atarax, Vistaril hydroxyzine
Ativan lorazepam
Centrax prazepam
Equanil, Miltown meprobamate
Librium chlordiazepoxide
Paxipam halazepam
Serax oxazepam
Valium diazepam
Xanax alprazolam
Anti-spasmodics:
Anaspaz hyoscyamine
Atropisol, Sal-Tropine atropine
Banthine methantheline
Bellergal belladonna alkaloids
Bentyl dicyclomine
Daricon oxyphencyclimine
Ditropan oxybutynin
Librax clidinium
Pamine methscopolamine
Pro-Banthine propantheline
Transderm-Scop scopolamine
Anti-convulsants:
Felbatol felbamate
Lamictal lamotrigine
Neurontin gabapentin
Tegretol carbamazepine
Anti-depressants:
Anafranil clomipramine
Asendin amoxapine
Elavil amitriptyline
Luvox fluvoxamine
Norpramin desipramine
Paxil paroxetine
Sinequan doxepin
Tofranil imipramine
Wellbutrin bupropion
Anti-diarrheals:
Imodium AD loperaminde
Lomotil diphenoxylate
Motofen difenoxin
Anti-histamines:
Actifed pseudoephedrine
Benadryl diphenhydramine
Chlor-Trimeton chlorpheniramine
Claritin loratadine
Dimetane, Dimetapp brompheniramine
Hismanal axtemizole
Phenergan promethazine
Pyribenzamine (PBZ) tripelennamine
Seldane terfenadine
Brand Name:
Generic Name:
Anti-hypertensives:
Capoten captopril
Catapres clonidine
Coreg carvedilol
Ismelin guanethidine
Minipress prazosin
Serpasil reserpine
Wytensin guanabenz
Anti-inflammatory analgesics:
Feldene piroxicam
Motrin ibuprofen
Nalfon fenoprofen
Naprosyn naproxen
Anti-nauseant:
Antivert meclizine
Dramamine diphenhydramine
Marezine cyclizine
Anti-Parkinsonian:
Akineton biperiden
Artane trihexyphenidyl
Cogentin benztropine
Larodopa levodopa
Sinemet carbidopa
Anti-psychotics:
Clozaril clozapine
Compazine prochlorperazine
Carbolith, Duralith, Eskalith lithium
Haldol haloperidol
Mellaril thioridazine
Navane thiothixene
Orap pimozide
Sparine promazine
Stelazine trifluoperazine
Thorazine chlorpromazine
Bronchodilators:
Atrovent ipratropium
Isuprel isoproterenol
Proventil, Ventolin albuterol
Decongestants:
Ornade chlorpheniramine
Sudafed pseudoephedrine
Diuretics:
Diuril chlorothiazide
Dyazide, Maxzide triamterene
HydroDiuril, Esidrix hydrochlorothiazide
Hygroton chlorthalidone
Lasix furosemide
Midamor amiloride
Muscle relaxants:
Flexeril cyclobenzaprine
Lioresal baclofen
Norflex, Disipal orphenadrine
Narcotic analgesics:
Demerol meperidine
MS Contin morphine
Sedatives:
Dalmane flurazepam
Halcion triazolam
Restoril temazepam