Management of a Dry Mouth  (Xerostomia)

Trey L. Petty, DDS

Foothills Medical Centre, Oral Medicine

403/ 670-2401     trey.petty@CalgaryHealthRegion.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)

 

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