Palliative care assessment of dry mouth: what matters most to patients with advanced disease?

PURPOSE: Dry mouth is a highly prevalent and significant symptom in patients with advanced progressive diseases. It is a poorly understood area of research, and currently, there is no standardised outcome measure or assessment tool for dry mouth. METHODS: To assess responses to self-reported dry mouth questions, the impact of dry mouth, methods used to reduce symptoms and relevance of the questionnaire. A cross-sectional multisite study of 135 patients with advanced progressive disease experiencing dry mouth. Participants were located in the inpatient, day care, outpatient or community setting. RESULTS: The majority (84.4%) of patients rated their dry mouth as moderate or severe using the verbal rating scale (VRS). Seventy-five percent (74.7%) had a numeric rating scale (NRS) score of 6 or more for dry mouth severity. Patients reported that dry mouth interfered most with talking and was the most important function to assess (median score 6 out of 10) followed by eating (median 5) and taste (median 5). Taking sips of drink was the most common and most effective self-management strategy. Over half of patients (54.6%) also reported impact on swallow and sleep and associated dryness of lips, throat and nasal passages. CONCLUSIONS: This study highlights the severity of dry mouth in advanced disease. Important factors when assessing patients with dry mouth should include the functional impact on day-to-day activities including talking, dysphagia and sleep. Simple considerations for patients include provision of drinks and reviewing medications. This study could be used to develop a standardised assessment tool for dry mouth to use in clinical practice.

Clinical Care for an Aging Population.

Pathologic changes in the oral cavity can portend the presence of systemic diseases and result in poor oral health and tooth loss, which are commonly symbolic of aging. Systemic diseases can have direct and indirect effects on oral health, and, likewise, poor oral health can impact general health and wellbeing. Negligence in oral care results in the accumulation of dental plaque and calculus, which eventually contributes to the onset of dental caries, periodontal disease, halitosis, tooth loss, and, ultimately, diminished oral function. Some oral pathology also increases in prevalence in older adults. However, diminished oral health and function is not a normal result of aging. Providing appropriate oral healthcare to frail and medically compromised adults requires an interprofessional approach to address the many diseases and conditions that can impact oral health and the safe and timely provision of care. As opportunities increase for oral healthcare professionals to function as integral members of interdisciplinary teams and to practice in nontraditional and more accessible settings, clinicians may gain better understanding of the dynamic balance between oral and general health, and how the social determinants of health can be leveraged to favor both.

[Research progress of xerostomia assessment tools].

Xerostomia is an important problem affecting oral health and quality of life, and effective assessment is the basis of management of xerostomia. This review summarizes the subjective and objective assessment tools for xerostomia, so as to provide references for the evaluation and management of xerostomia.

Dry mouth: a critical topic for older adult patients.

PURPOSE: Diminished salivary flow, or dry mouth impacts the oral health of many older adults, dentate and edentulous. As a result typical oral conditions can prove more challenging to both the patient's comfort and home care and the treatment selected by the clinician. This paper will review issues of dry mouth from a clinical and symptomatic perspective and will include the condition's causes, treatment and prevention. STUDY SELECTION: We performed a review of PubMed using the words: older adults, dry mouth, xerostomia, radiation-induced xerostomia, and salivary gland hypofunction. We selected 90 articles with a clinical application perspective. RESULTS: When it comes to treatment of dry mouth conditions, either objective or subjective, there are no easy answers as to the best course of action for a specific individual. While most of the cited studies have examined the most difficult cases of dry mouth (e.g., Sjögren's syndrome, and that seen during and post head and neck cancer treatments), there are many older adults who demonstrate dry mouth from the use of multiple medications. This paper presents a summary of the etiology, diagnosis, prevention, and pharmacological and non-pharmacological treatment of dry mouth (salivary hypofunction and xerostomia in older adults). CONCLUSIONS: It is important to understand the causes of dry mouth and to educate our patients. Starting a prevention program as early as possible considering the most practical, cost effective and efficient treatments with the best risk-benefit ratio will help to diminish dry mouth symptoms and sequelae.

A pilot study to assess oral health literacy by comparing a word recognition and comprehension tool.

BACKGROUND: Oral health literacy is important to oral health outcomes. Very little has been established on comparing word recognition to comprehension in oral health literacy especially in older adults. Our goal was to compare methods to measure oral health literacy in older adults by using the Rapid Estimate of Literacy in Dentistry (REALD-30) tool including word recognition and comprehension and by assessing comprehension of a brochure about dry mouth. METHODS: 75 males and 75 females were recruited from the University of Connecticut Dental practice. Participants were English speakers and at least 50 years of age. They were asked to read the REALD-30 words out loud (word recognition) and then define them (comprehension). Each correctly-pronounced and defined word was scored 1 for total REALD-30 word recognition and REALD-30 comprehension scores of 0-30. Participants then read the National Institute of Dental and Craniofacial Research brochure "Dry Mouth" and answered three questions defining dry mouth, causes and treatment. Participants also completed a survey on dental behavior. RESULTS: Participants scored higher on REALD-30 word recognition with a mean of 22.98 (SD = 5.1) compared to REALD-30 comprehension with a mean of 16.1 (SD = 4.3). The mean score on the brochure comprehension was 5.1 of a possible total of 7 (SD = 1.6). Pearson correlations demonstrated significant associations among the three measures. Multivariate regression showed that females and those with higher education had significantly higher scores on REALD-30 word-recognition, and dry mouth brochure questions. Being white was significantly related to higher REALD-30 recognition and comprehension scores but not to the scores on the brochure. CONCLUSIONS: This pilot study demonstrates the feasibility of using the REALD-30 and a brochure to assess literacy in a University setting among older adults. Participants had higher scores on the word recognition than on comprehension agreeing with other studies that recognition does not imply understanding.

Cost-effectiveness landscape analysis of treatments addressing xerostomia in patients receiving head and neck radiation therapy.

Head and neck (H&N) radiation therapy (RT) can induce irreversible damage to the salivary glands thereby causing long-term xerostomia or dry mouth in 68%-85% of the patients. Not only does xerostomia significantly impair patients' quality-of-life (QOL) but it also has important medical sequelae, incurring high medical and dental costs. In this article, we review various measures to assess xerostomia and evaluate current and emerging solutions to address this condition in H&N cancer patients. These solutions typically seek to accomplish 1 of the 4 objectives: (1) to protect the salivary glands during RT, (2) to stimulate the remaining gland function, (3) to treat the symptoms of xerostomia, or (4) to regenerate the salivary glands. For each treatment, we assess its mechanisms of action, efficacy, safety, clinical utilization, and cost. We conclude that intensity-modulated radiation therapy is both the most widely used prevention approach and the most cost-effective existing solution and we highlight novel and promising techniques on the cost-effectiveness landscape.

Enhancing the quality of life in elderly women through a programme to improve the condition of salivary hypofunction.

OBJECTIVE: The purposes of this study were to examine the effects of oral exercise intended to improve the function of the oral cavity in the elderly and their quality of life to pave the way for the development of oral-health promotion programmes geared towards the elderly. METHODS: The subjects were 78 female Koreans who resided in Seoul and were aged 65 years and older. During a 3-month period, an oral function promotion programme was conducted twice a week, between 10.00 am and 12.00 pm, applying oral exercise suggested by a Japanese public health centre. A survey was conducted by interviewing the selected women to determine the state of their subjective dry mouth, quality of life related to oral health and jaw functional limitation. Their opening, unstimulated whole saliva and pronunciation speed were measured before and after the oral function exercise programme. RESULTS: The subjects showed a significant improvement in subjective dry mouth symptoms, relevant behaviour, the level of discomfort caused by dry mouth and subjective jaw functional limitation during mastication and swallowing and emotional expression after receiving the oral exercise. After the oral exercise, there was a significant increase in mouth opening, unstimulated whole saliva and speaking speed ('patakala' pronunciation) after oral exercise. There was also significant progress in their quality of life related to oral health. Overall improvement in subjective dry mouth symptoms and relevant behaviour over time after oral exercise had a positive correlation with the level of improvement in discomfort triggered by dry mouth and mastication. The level of improvement in OHIP-14 had a positive correlation with the level of overall improvement in dry mouth symptoms and behaviour, the level of improvement in discomfort by dry mouth and that in mastication and swallowing. CONCLUSION: This study showed the effects of the oral function promotion programme and correlation of oral condition and oral health-related quality of life. It is suggested that this oral function promotion programme has positive effects on both objective and subjective oral conditions. It is strongly recommended that this programme, along with other oral health promotion programmes, be implemented to improve oral function and oral health-related quality of life for the elderly.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: management strategies and economic impact.

PURPOSE: This systematic review aimed to assess the literature for management strategies and economic impact of salivary gland hypofunction and xerostomia induced by cancer therapies and to determine the quality of evidence-based management recommendations. METHODS: The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. For each article, two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results, and conclusions. RESULTS: Seventy-two interventional studies met the inclusion criteria. In addition, 49 intensity-modulated radiation therapy (IMRT) studies were included as a management strategy aiming for less salivary gland damage. Management guideline recommendations were drawn up for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer. CONCLUSIONS: There is evidence that salivary gland hypofunction and xerostomia induced by cancer therapies can be prevented or symptoms be minimized to some degree, depending on the type of cancer treatment. Management guideline recommendations are provided for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer. Fields of sparse literature identified included effects of gustatory and masticatory stimulation, specific oral mucosal lubricant formulas, submandibular gland transfer, acupuncture, hyperbaric oxygen treatment, management strategies in pediatric cancer populations, and the economic consequences of salivary gland hypofunction and xerostomia.

Xerostomia: prevalence, diagnosis, and management.

This article summarizes the common causes, clinical presentation, and complications of xerostomia and salivary gland hypofunction in the geriatric population and discusses the various management options.

Evaluation of an oral function promotion programme for the independent elderly in Japan.

OBJECTIVES: The purpose of this study was to provide an oral function promotion programme for the independent elderly and evaluate the changes in oral health status and oral function. BACKGROUND: Few studies have scientifically analysed and evaluated the effectiveness of oral function promotion programmes provided for the independent elderly. MATERIALS AND METHODS: The subjects were independent elderly females (mean age: 74.6 +/- 6.3) recruited from senior citizens' centres in Tokyo. The intervention group (n = 79) received a 3-month oral function promotion programme, which included facial muscle and tongue exercises and salivary gland massages. The control group (n = 62) did not receive this programme. RESULTS: In the intervention group, the tongue coating scores decreased and the organoleptic score of oral malodour fell. The amount of food debris in the oral cavity decreased and the tongue dryness improved. Furthermore, the salivary flow rate increased. The length of time for maintaining the tongue in the forward position increased from 11.2 s to 18.7 s, and the number of times for moving the tip of the tongue in a clockwise circular motion, counter-clockwise circular motion and side-to-side motion within 30 s, increased from 14.5 to 20.6, 14.5 to 20.2, and 17.2 to 23.3 respectively. The number of times for movement of the lips significantly improved from 23.0 to 28.8 and the pronunciation of words was observed to be clearer. CONCLUSION: An oral function promotion programme was effective in improving the oral health status and oral function of an independent elderly population.

Subjective assessment of a new moisturizing mouthwash for the symptomatic management of dry mouth.

OBJECTIVE: A randomized clinical trial and consumer usage test were conducted to evaluate the acceptability and benefits of OASIS Moisturizing Mouthwash in subjects experiencing symptoms of dry mouth. METHODOLOGY: Study 1: A randomized, double blind, two-period crossover clinical trial was conducted in 49 subjects to evaluate OASIS Moisturizing Mouthwash and an experimental mouthwash formulation. Following a three-day acclimatization phase, subjects used both products at home for three days. Each treatment phase was separated by a three-day washout period. Study 2: Subjects participated in a one- to two-week home usage consumer test using OASIS Moisturizing Mouthwash, after which they completed a 52-question online survey exploring sensory benefits and resultant quality of life attributes of the product. RESULTS: Study 1: A total of 46 adults with a mean age of 64 years completed the study. On average, subjects used the test products three times per day. OASIS Moisturizing Mouthwash was found to be beneficial in managing dry mouth, and was well-liked by the study population, as evidenced by a statistically significant improvement over subjects' normal remedies for managing dry mouth for strength of flavor, taste, freshening breath, immediate and long lasting lubrication, and moisturization. Both products were well-tolerated. Study 2: Three-hundred and twenty-three subjects completed a one- to two-week consumer home usage test followed by an online questionnaire. On a five-point scale, over 80% of respondents perceived the OASIS Moisturizing Mouthwash as "excellent" or "very good" on sensory attributes such as taste and texture, and 70-80% gave the product an "excellent" or "very good" rating on benefit attributes. CONCLUSION: These studies showed that OASIS Moisturizing Mouthwash was beneficial in managing dry mouth, and was well-liked by the study population.

Subjective assessment of a new moisturizing mouth spray for the symptomatic relief of dry mouth.

OBJECTIVE: A randomized clinical trial (Study 1) and consumer usage test (Study 2) were conducted to evaluate the acceptability and efficacy of OASIS Mouth Moisturizing Spray in subjects experiencing dry mouth. METHODOLOGY: Study 1: A randomized, single-blind, four-arm crossover clinical trial was conducted in 24 subjects, ranging from 50-84 years of age, to evaluate OASIS Mouth Moisturizing Spray and two experimental mouth spray formulations, and compare their performance to a reference (marketed) mouth spray, SALIVEZE. Following a three-day acclimatization phase, subjects used all four products at home for three days. Each treatment phase was separated by a three-day washout period. Study 2: One-hundred twenty subjects participated in a three-week home usage consumer test using OASIS Mouth Moisturizing Spray, after which they completed a 52-question online survey exploring sensory, efficacy, and resultant quality of life attributes of the product. RESULTS: Study 1: On average, subjects used the four test products 2-3 times per day. OASIS Mouth Moisturizing Spray was found to be effective in relieving dry mouth in the study population, as evidenced by a statistically significant feeling of coating the mouth (p < 0.05), and statistically significantly longer dry mouth relief (p < 0.005) than the commercial control. The OASIS Mouth Moisturizing Spray was statistically significantly (p < 0.05) better and preferred over the other product tested. All the products used in the study were well-tolerated. Study 2: On a five-point scale, 73% of respondents perceived the OASIS Mouth Moisturizing Spray as "very good" or "excellent," and more than 60% gave the product an "excellent" or "very good" rating on sensory, efficacy, and quality of life attributes. CONCLUSION: These studies show that OASIS Mouth Moisturizing Spray helped provide dry mouth relief and was well liked by the study population.

Extended formulary nurse prescribing--another saliva substitute roadblock.

United Kingdom family physicians, General Practitioners (GPs), are allowed to prescribe from a Department of Health-approved list of non-medicines (the 'ACBS' list) which includes a majority of proprietary saliva substitutes. Independent nurse prescribing, introduced in 2001, has improved patient access to effective remedies for a wide range of common medical problems. Further qualified 'extended formulary nurse prescribers' have access to a limited range of prescription medicines, and all non-prescription medicines that GPs may currently prescribe. Despite their specified role in the management of oral complications encountered in palliative care, a similar anomaly in NHS rules that prevents dental practitioners from prescribing ACBS listed saliva substitutes also prevents nurses from prescribing them. Sadly, patients are suffering poorer access to simple and effective remedies to conditions such as xerostomia - a condition that has recognised impact on their quality of life.