Xerostomia: Looking with Fresh Eyes to Reduce Dry Mouth

EARN This course was written for dentists, 3 CE dental hygienists, CREDITS and assistants.

Xerostomia: Looking with fresh eyes to reduce dry mouth

A peer-reviewed article written by Alisa Cooper, DC

PUBLICATION DATE: APRIL 2019

EXPIRATION DATE: MARCH 2022

SUPPLEMENT TO PENNWELL PUBLICATIONS EARN This educational activity was developed by PennWell’s Dental Group with no commercial support. 3 CE This course was written for dentists, dental CREDITS hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Laura Winfield, CE Coordinator does not have a leadership or commercial interest with Xerostomia: Looking with fresh products or services discussed in this educational activity. Laura can be reached at [email protected] eyes to reduce dry mouth Educational Disclaimer: Completing a single continuing education course does not provide enough information LEARNING OBJECTIVES to result in the participant being an expert in the field related to the course topic. It is a combination of many This course is designed to help dental professionals do the following: educational courses and clinical experience that allows 1. Understand the etiology of xerostomia the participant to develop skills and expertise. Image Authenticity Statement: The images in this 2. Identify the signs and symptoms of xerostomia educational activity have not been altered. 3. Compare treatments for xerostomia Scientific Integrity Statement: Information shared in 4. Educate patients about xerostomia and offer compassionate support this CE course is developed from clinical research and represents the most current information available from 5. Recommend safe, effective products to help patients manage the condition evidence based dentistry. at home Known Benefits and Limitations of the Data: The information presented in this educational activity ABSTRACT is derived from the data and information contained in reference section. The research data is extensive and Xerostomia is a term that describes the feeling of having a dry mouth, whether provides direct benefit to the patient and improvements as a perceived sensation or the result of salivary gland hypofunction. Regard- in oral health. Registration: The cost of this CE course is $59.00 for 3 less of cause, it manifests as a cluster of signs and symptoms encountered in CE credits. dental practice frequently. While occasional mouth dryness is normal, chronic Cancellation/Refund Policy: Any participant who is not dry mouth can have devastating consequences on oral health and quality of 100% satisfied with this course can request a full refund life. Dental professionals can have a profound impact on xerostomia patients by contacting PennWell in writing. by preventing and mitigating related oral complications. Furthermore, dental professionals can educate patients on how best to cope with the condition. This course emphasizes clinical presentation, etiology, and available treatments for xerostomia. Also included is a review of popular oral health products—along with patient comments—to help practitioners guide patients through the plethora of over-the-counter treatment options. PennWell designates this activity for 3 continuing educational credits. Dental Board of California: Provider 4527, course registration number CA code: 03-4527-15337 “This course meets the Dental Board of California’s requirements for 3 units of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452.

PennWell is an ADA CERP recognized provider

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP Go Green, Go Online to take your course at www.ada.org/goto/cerp. www.DentalAcademyofCE.com QUICK ACCESS CODE 15337 DENTAL ACADEMY OF CONTINUING EDUCATION

INTRODUCTION parotid, submandibular, and sublingual. It Most people experience a dry mouth from is involved in lubrication, digestion, taste, time to time, whether it be from dehydration, buffering, protection, and clearance.3 mouth breathing due to allergies, or consum- Saliva eases normal frictional movements ing dehydrating beverages. It is also common and provides the lubrication that makes for people’s mouths to go dry if called upon swallowing, speaking, and eating possible to speak publicly, when the body’s fight-or- and comfortable.5 Besides initiating diges- flight response makes it difficult to muster tion, saliva is the solvent that allows for taste Figure 1: Angular chelitis the moisture needed for articulation. While sensation and the enjoyment of food. At a a few deep breaths and a sip of water may pH of 6–7, saliva neutralizes acids to rem- Xerostomic patients frequently experi- solve temporary dryness, when the condi- ineralize the teeth and maintain a healthy ence cotton mouth and chapped, peeling, tion is chronic, the effects can be life-altering. oral microbiome. Protecting the oral mucosa or cracked lips (figure 1), and inflamma- In the first section of this course, we will from injury, trauma, burns, and infection, tion at the corners of the mouth (angular look at how dental professionals can recog- saliva also washes away food debris to ward cheilitis; figure 1). Many experience hoarse- nize xerostomia. We will then look at etiol- off oral malodor and prevent dental car- ness, coughing, and difficulty wearing their ogy of xerostomia. Finally, we will look at ies and gum disease.1–3,5 A lack of adequate dentures. When saliva is lacking, prostheses xerostomia treatment. saliva impairs these crucial functions, lead- generally become less stable and surround- ing to adverse effects on dental health and ing tissue more vulnerable to trauma and RECOGNIZING XEROSTOMIA quality of life. ulceration. Additionally, xerostomia requires Xerostomia is the term used to describe a hydration throughout the day and night, collection of signs and symptoms associated Signs and symptoms resulting in multiple bothersome trips to with mouth dryness. Derived from the Greek Signs and symptoms of xerostomia can range the bathroom.3–6 words xeros for “dry” and stoma for “mouth,” from mild discomfort to significant pain Following a detailed case history, an oral xerostomia includes both the subjective feel- and dysfunction. Besides a dry mouth and examination will provide evidence of xero- ing of having a dry mouth as well as an objec- throat, the patient may have trouble speak- stomia. Telltale signs include the absence of tive decrease in saliva flow.1-3 ing, chewing, and swallowing, and have a saliva pooling on the floor of the oral cavity diminished or abnormal taste sensation and/or saliva that appears stringy or frothy. Incidence (dysgeusia).3 Some patients complain of A dry, red, or cracked tongue may be lack- Xerostomia, which increases with age for burning in the mouth and intolerance for ing normal papillae or be coated white7 with both sexes, affects approximately 20% of spicy, dry, acidic, or crunchy foods.4 candidiasis (figure 2). the population. Elderly females experience a higher prevalence of dry mouth, which may be due to postmenopausal decline in hormones.3 The fact that more seniors experience xerostomia is due to a complex interplay between aging, systemic diseases, and polypharmacy, the simultaneous use of several prescription medications for one or more conditions.2,4 Studies show that the world’s geriatric population is growing. As dental professionals strive to meet their patients’ needs, it is important to have a thorough understanding of xerostomia.2

The role of saliva To fully understand the effects of xerostomia on health and well-being, it is important to review the functions and benefits of saliva. The normal daily production of saliva ranges between 0.5 and 1.5 liters and consists of an aqueous fluid rich in electro- lytes, minerals, enzymes, buffering agents, Timonina - Dreamstime.com © Iryna immunoglobulins, and urea.1 Saliva is pro- duced by three primary salivary glands, the Figure 2: Candidiasis

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Additionally, the gums may be pale and the pain may also induce xerostomia.1,4,8 compromises salivary function—often per- oral mucosa may be glossy and smooth. Gin- A correlation exists between increasing dry manently.9,10 Figure 3 below depicts the main givitis, periodontitis, and dental erosion of the mouth symptoms and the number of medica- salivary glands. Note the superficial loca- cervical and incisal/cuspid tips may be seen tions used. For example, in 20- to 80-year-old tion that makes them vulnerable to dam- in chronic xerostomia.4,5,7 Table 1 summarizes patients taking no medications, 17% had per- age during radiotherapy for deeper head the signs and symptoms of xerostomia.3,5–7 ceived symptoms of dry mouth. That number and neck tumors. increased to 33.5% for those taking three med- Radiotherapy-induced damage to the ETIOLOGY OF XEROSTOMIA ications and to 67% for those taking seven or salivary glands is evident in half of patients Medication more. Unfortunately, polypharmacy is most within the first week of treatment.1 For many The most common cause of xerostomia is prevalent among senior citizens, for whom patients, decrease in salivation continues prescription medication. More than 400 xerostomia is more likely caused by medica- over time, leading to permanent xerosto- medications are known to cause dry mouth, tions rather than aging.4,6,8 mia, loss of taste, and consequent challenges with over 70% of individuals who take them obtaining adequate nutrition.1,9 suffering from this side effect.1,4,8 The most Radiotherapy common culprits include tricyclic antidepres- Xerostomia often occurs in patients being Sjögren’s syndrome sants, antipsychotics, beta blockers, antihis- treated with radiotherapy for head and Xerostomia is a predominant symptom for tamines, and antihypertensives. Additionally, neck cancers. These cancers thrive in the individuals suffering from Sjögren’s syn- drugs prescribed for smoking cessation, to moist mucosal lining of the oral and nasal drome, a complex autoimmune condition control acne, to reduce symptoms of Parkin- cavities, paranasal sinuses, pharynx, and of unknown etiology. While widespread organ son’s, and to treat an overactive bladder can larynx. Although head and neck cancers involvement is common, the condition is also result in mouth dryness. Nonsteroidal can originate in the salivary glands, they most well-known for attacking secretory cells anti-inflammatories (NSAIDS), such as ibu- are rare. Radiation passing through these of salivary and lacrimal glands, leading to the profen and naproxen, taken for garden-variety superficial glands to reach malignant tumors characteristic dry mouth and dry eyes.1,11,12

Table 1: Signs and symptoms of xerostomia Dry feeling in mouth and/or throat

Frequent thirst

Frequent coughing

Difficulty speaking, chewing, swallowing (dysphagia) Abnormal taste sensation (dysgeusia)

Sensitivity to spicy foods Parotid Hoarseness, sore throat gland

Chapped, cracked, and/or peeling lips

Pale gums

Stringy and/or sticky saliva

Bad breath

Sores at corners of the mouth (cheilitis)

Difficulty wearing dentures

Coated, white tongue (candidiasis)

Burning, tingling sensation in the oral cavity, tongue Submandibular gland Painful tongue (glossodynia), tonuge fissures, and ulcers Dry, rough, or red tongue

Increased tooth decay, erosion, and gum disease

Mouth sores Sublingual glands

Swollen and/or painful salivary glands Figure 3: Salivary gland anatomy36

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A combination of influences may underlie Figure 4: Cracked, fissured tongue the hyperactive immune response typical of Sjögren’s syndrome. With a predilection for women over men at a ratio of 9:1, middle- 11 aged females are most at risk. Regardless Halitosis of cause, attempts are made to stimulate the salivary glands and/or to provide suitable saliva substitutes. Since xerostomia in these patients can be devastating, the focus of dental professionals is to help patients maintain oral health and minimize complications.12 Figure 4 illustrates a sore, cracked tongue often seen in patients with Sjögren’s syndrome along with accompanying halitosis.

Other contributing factors Lifestyle habits can result in xerostomia that is transient or potentially reversible. Smok- ing, drinking alcohol, using mouthwashes containing alcohol, and consuming caffein- Fissured Bacteria reproduce in the ssures ated beverages can all contribute to the expe- tongue and cause halitosis rience of oral dryness. So too can chronic dehydration, snoring, mouth breathing due © Rob3000 | Dreamstime.com to allergies or congestion, and the wearing of mouthguards or dentures while sleeping.2,4 maintain an unrealistic self-image and body caries, erosion, and dysphagia. Figure 5 Anxiety and depression are psychologi- weight. Bulimia may affect as many as 5 mil- shows eroded teeth in a patient with bulimia. cal factors that can influence salivary gland lion Americans annually, including 10-20% Diminished salivary flow may also be function and result in xerostomia. In cases of all college females.16 caused by overuse of diuretics and laxa- of anxiety, increased cortisol levels alter the Dental professionals may encounter tives and the dehydration that comes with proteins in saliva, which leads to xerostomia. bulimic patients with tooth erosion. This fasting, as in anorexia, and vomiting, as in With depression, anticholinergic mecha- results from the presence of gastric contents bulimia.17 In addition to restoring eroded nisms directly decrease salivary flow.13 Con- in the oral cavity over time. Ensuing dam- teeth, dental professionals make necessary versing with patients about how common age to the salivary glands leads to hyposal- referrals for medical treatment and psycho- habits and psychological factors contribute ivation and xerostomia, promoting dental logical counseling.16 to xerostomia may provide impetus for lifestyle modifications, stress management, and ancillary treatment. Xerostomia occurs in many chronic systemic diseases. It is seen in patients with diabetes mellitus, hepatitis C, hyperten- sion, Epstein-Barr virus, sarcoidosis, HIV, kidney disease, and Parkinson’s. Common in Alzheimer’s and stroke patients, dry mouth is mostly a perceived sensation. Patients with connective tissue disorders such as rheuma- toid arthritis and systemic lupus erythema- tosus may also experience xerostomia.3,14,15 Eating disorders, such as anorexia and bulimia nervosa, affect the oral cavity and can cause xerostomia. Bulimia nervosa is characterized by episodes of unrestrained eating followed by forced vomiting. This binge/purge syndrome is seen mostly Figure 5: Veneers and composites were placed in a patient who had previously been diagnosed with an eating in young adult women who struggle to disorder and subsequently began bulimic practices again.37

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Illicit drugs cause xerostomia and its activates the micturition reflex. This stimu- chewing gum, glycerin-containing lubri- adverse effects on dental health.18 Opiates lates the bladder to release its water before cants, adherent oral disk technology, alco- are known for causing constipation, but dry the body can absorb it at the cellular level hol-free mouthwashes, rinses, toothpastes, mouth is another symptom endured while to hydrate the body.22,23 and oral sprays.1-4 Dental professionals can in the throes of addiction. Even suboxone Important dietary modifications introduce patients to safe and effective prod- (buprenorphine), the drug used to help include avoiding spicy, sugary, sticky, dry, ucts that can reduce symptoms and improve addicts medically withdraw from opiates, and crumbly foods and replacing them with quality of life. The table below highlights causes dry mouth, predisposing to gingivi- nutrient-dense, hydrating foods such as cit- some popular products along with patient tis, periodontitis, and tooth loss.19 rus fruits, watermelon, celery, cucumbers, comments.27-34 Methamphetamines stimulate a salads, and stews. Electrostimulation is a nonmedical hypervigilant sympathetic nervous system Avoiding dehydrating beverages such as modality that holds promise for the relief response that results in xerostomia and con- coffee, soda, and alcohol in excess and incor- of severe xerostomia. Intraoral removable sequent tooth erosions. Additionally, the porating lemon water, aloe vera juice, herbal devices provide electric stimulation to the term “meth mouth” refers to a constella- teas, and coconut water are also beneficial.24,25 oral mucosa, resulting in a measurable tion of oral symptoms, including excessive Limiting tobacco use, addressing root causes decrease in oral dryness. Traditional acu- teeth grinding, jaw clenching, and TMJ and of snoring and mouth breathing, and employ- puncture may increase saliva flow lasting related muscle spasms among its 35 million ing a humidifier at night are recommended.2,4 for up to six months. With additional treat- users worldwide.18 When medications are the cause of xero- ments, this improvement may last for up Cannabis (marijuana) use increases the stomia, dosages may be reduced, and medi- to three years. risk of xerostomia and candidiasis. Chronic cations with a different mechanism of action Studies also suggest that hyperbaric oxy- users may eventually suffer from premature may be considered.1,4 Some may obtain relief gen treatments decrease xerostomia and tooth loss along with difficulty speaking and by limiting medications to daytime use or tissue necrosis following radiotherapy. Addi- eating due to hyposalivation.20 As the popu- taking their medications in divided doses tional research is needed to ascertain the larity of these drugs continues to rise, dental throughout the day.1,7 It is also advisable for effectiveness of these modalities as natural, professionals are increasingly called upon to patients to work with their health-care pro- sustainable ways to combat xerostomia.3,26 treat related oral conditions while encour- viders to reduce reliance on prescription Lastly, meticulous oral care is central aging long-term rehabilitative treatment.18 drugs since individuals taking four or more to the treatment of xerostomia. Frequent Approximately 1.5 million Americans suf- are more likely to suffer from xerostomia.2,4 dental checkups minimize tooth decay, fer from burning mouth syndrome, or When xerostomia is severe, sialagogues periodontal disease, and infections. Tooth BMS, a painful oral disorder that can result may be prescribed. These medications stim- brushing, flossing, mouth rinsing, and the in xerostomia. Affecting primarily peri- and ulate salivary flow when salivary glands use of a Waterpik and tongue scraper are postmenopausal women, two thirds of BMS retain some functional capacity. Pilocar- vital for self-care at home.1–4 Oil pulling, an victims suffer from xerostomia, and some pine (Salagen®) benefits approximately Ayurvedic practice known for improving oral experience abnormal taste sensation. Burn- 50% of patients with xerostomia following health, may also help. It entails pulling coco- ing, itching, and stinging in the oral cavity, radiotherapy for head and neck cancers.1-3,6 nut, olive, or sesame oil through the teeth especially the tongue, can arise spontane- Available orally in pastilles and lozenges, and swishing for up to 20 minutes before ously and last for at least four to six months. pilocarpine must be taken on a lifelong basis. expectorating and rinsing to remove toxins. Originally thought to be a psychiatric disor- Unfortunately, common side effects include Anecdotal evidence is favorable, but further der, the incidence of BMS in various medical sweating, skin flushing, nausea, diarrhea, research is needed to determine its efficacy conditions suggests a multifactorial etiology. headache, dizziness, dyspepsia, and urinary in addressing xerostomia.35 A menopausal decline in estrogen, which frequency. Pilocarpine must be used cau- protects mucous membranes, may explain tiously in those with pulmonary and cardiac CONCLUSION its prevalence in middle-aged women.21 disease and is contraindicated in patients Xerostomia, a common condition stemming with narrow-angle glaucoma.1,3-5,7,11,26. from a variety of causes, can have devastat- TREATMENT AND MANAGEMENT OF Cevimeline (Evoxac®) is a sialagogue that ing consequences on oral health and quality XEROSTOMIA can be used as an alternative to pilocarpine of life. While no cure exists, many treatment The treatment of xerostomia often begins since it is better tolerated by the heart and options are available to reduce its adverse with implementing lifestyle changes. lungs. While 70% of those using cevimeline effects. Dental professionals can be a vital Attempts are made to maintain adequate experience side effects, most report them resource for xerostomia patients by optimiz- hydration by drinking at least eight 8-ounce as mild to moderate and limited to causing ing their oral health, providing education glasses of quality water per day. Also, sip- sweating and dyspepsia.1,3,26 about the condition, and offering compas- ping water throughout the day rather Many nonmedical treatments exist for sionate support. than gulping large amounts periodically is xerostomia. Saliva substitutes and stim- advised. Swallowing large quantities of water ulants include lozenges, xylitol-sweetened

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Table 2: An assortment of dry mouth products DESCRIPTION PATIENT COMMENTS

XyliMelts are disks made with xylitol, a natural sweetener that helps “After years of dry mouth sprays and lozenges, my hygienist recom- stimulate saliva flow and may reduce the risk of tooth decay. The mended XyliMelts and gave me a sample. I called back and told her disks adhere to the teeth or gums and can be worn day or night to they were wonderful and so simple. You can even put one on both temporarily relieve dry mouth. sides for an extended time. XyliMelts moisturize and coat the mouth by releasing xylitol over time. “Being a veterinarian, it was either “cotton mouth” or choking on Xylimelts lozenges. Now I can drink water and use XyliMelts through lengthy Individuals allergic to adhesive may need to proceed with caution. procedures.” Xylitol is lethal to dogs and must be kept out of their reach.

The Biotène line of products includes a moisturizing gel, oral rinse, and mouth spray formulated to moisturize and refresh the mouth by “I have serious problems with dry mouth from the medications I matching the pH of saliva. take. While this stuff certainly isn’t something I would want to con- sume as a ‘treat,’ it definitely does the job it’s supposed to! Biotène toothpaste is formulated to be moisturizing and nonirritat-

Biotène ing. Biotène products are considered generally safe. Like all other “A few quick sprays into my mouth after brushing my teeth in the oral care products, they should not be swallowed and must be kept morning, and no problems with my lips sticking to my teeth!” out of reach of children.

“I've used Spry Xylitol Rinse for about a year and I now depend on Xlear is a leading manufacturer of xylitol-based products in North it to relieve dry mouth while I sleep. I use a toothpaste for sensitive America. Their non-GMO dental line of oral care products, Spry, teeth and it does not conflict with that. contains xylitol. “I've had no problems with my teeth since using this regularly. Products include Peppermint Gum, Cool Mint Oral Rinse, Berry Blast Xlear Mints, and Fluoride-free Peppermint Toothpaste. For best results, “It says to keep the rinse in your mouth for one minute, and it can Spry recommends using the full assortment of products throughout have a tingling, burning sensation, but it is worth it to be able to the day to ensure ongoing exposure to moisturizing xylitol. sleep through the night without waking up as though the Sahara Desert was in my mouth and throat.”

“Due to Sjögren’s, the tip of my tongue was always cracked and CloSYS Oral Health System is comprised of gentle products sore. I had embarrassing cotton mouth and constant thrush. My designed for sensitive mouths: alcohol-free oral rinses (flavored hygienist told me about CloSYS and it ended up being life changing and unflavored); CloSYS “Silver,” a fluoride rinse; CloSYS toothpaste for me. (available with or without fluoride); and a Fresh Breath oral spray.

PRODUCT/MANUFACTURER “My mouth isn’t as dry, and the thrush is kept at bay. My tongue CloSYS limits plaque, neutralizes sulfur compounds that cause CloSYS doesn’t crack, and I don’t require copious amounts of water that malodor, and reduces bacteria that contribute to gum and systemic had me running to the bathroom all the time. I know Sjögren’s pa- diseases. CloSYS has also been shown to alleviate oral mucositis tients who have lost their teeth, but CloSYS has enabled me to keep and relieve xerostomia. mine. I am so grateful.”

“I purchased (StellaFresh) to help with dry mouth and to preserve StellaLife offers VEGA Oral Care Solutions, an all-natural line of my teeth after chemotherapy treatments, and this product works oral health products that contain homeopathic ingredients with extremely well. anti-inflammatory and antimicrobial properties to reduce pain and optimize oral health. “It repaired my sore gums and inner jaw, which was cut up from lack of moisture, and my tongue, which I burnt on hot water be- VEGA Oral Care Gel temporarily reduces pain, swelling, and bruising. cause my tongue was so sensitive from having a dry mouth. StellaLife The VEGA Oral Rinse effectively fights bacteria, and the Oral Hydra- tion Mist hydrates the oral cavity and freshens the breath. “I will continue to use this after every chemo treatment and beyond.”

Hydris is Colgate’s product line specifically tailored for dry mouth “Great product. Definitely makes a difference in keeping my mouth conditions. Hydris Mouthwash is a mint-flavored rinse designed to moist due to a medicine I take that can be a problem. Have been us- keep the mouth hydrated for four hours. ing for a couple of weeks, but even after the first use, was hooked.

Hydris Hydris Dry Mouth Hydrating Toothpaste also provides relief from dry “It is a bit thicker than regular mouthwash but not to the point of be- mouth for up to four hours while freshening the breath and preventing unpleasant. Fresh taste and lasts till bedtime – I'm in!” ing cavities.

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(2018). Biotène® #1 Dentist Recommended Dry Mouth Brand | by radiotherapy: an overview of the physiopathology, clinical evidence, and Biotène®. [online] Available at: https://www.biotene.com/. Accessed Jul. 31, management of the oral damage. Therapeutics and Clinical Risk Management, 2018. 11, pp.171-188. 30. Amazon.com. (2018). Customer reviews Biotene oral rinse. [online] Available 10. National Cancer Institute. (2018). Head and neck cancers. [online] Available at: https://www.amazon.com/Biotene-Mouth-Oral-Rinse-Fresh/product-review. at: http://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet#q1. Accessed Jul. 31, 2018. Accessed Jul. 30, 2018. 31. Xlear. (2018). Spry dental defense - leaders in oral care xylitol products. 11. Tincani A, Andreoli L, Cavazzana I, Doria A, Favero M, Fenini M, Franceschini [online] Available at: http://www.xlear.com/spry-dental-defense/. Accessed Jul. F, Lojacono A, Nascimbeni G, Santoro A, Semeraro F, Toniati P, Shoenfeld Y. 31, 2018. (2013). Novel aspects of Sjögren’s syndrome in 2012. BMC Medicine, 11(1). 32. Closys.com. (2018). CloSYS - oral hygiene products, toothpaste, oral rinse & 12. Van der Reijden W, Vissink A, Veerman E, Amerongen A. (1999). Treatment of fresh breath spray. [online] Available at: https://closys.com/. Accessed Jul. 31, oral dryness related complaints (xerostomia) in Sjogren’s syndrome. Annals of 2018. the Rheumatic Diseases, 58(8), pp.465-474. 33. Stellalifehealing.com. (2018). Stellalife Consumer Reviews, available at: 13. Salah S. (2017). Effect of stress, anxiety and depression on unstimulated https://stellalifehealing.com/pages/consumers- Accessed Jul. 31, 2018. salivary flow rate and xerostomia. Journal of Dental Research, Dental Clinics, 34. Colgate.com. (2018). Dry mouth mouthwash & rinse | Colgate® Hydris™. Dental Prospects, [online] 11(4), pp.247-252. Available at: http://http;//www. [online] Available at: https://www.colgate.com/en-us/products/mouthwash/ joddd.tbzmed.ac.ir. Accessed Jul. 30, 2018. hydris. Accessed Jul. 31, 2018. 14. Baharvand M, Khodadoustan A, Mohammadi M, Mortazavi H, Movahhedian 35. Bradford A. (2015). Oil Pulling: Benefits & Side Effects. [online] Live Science. A. (2014). Xerostomia due to systemic disease: a review of 20 conditions Available at: https://www.livescience.com/50896-oil-pulling-facts.html. and mechanisms. Annals of Medical and Health Sciences Research, 4(4), Accessed Aug. 1, 2018. pp.503-510. 36. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. 15. López-Pintor R, Casañas E, González-Serrano J, Serrano J, Ramírez L, de WikiJournal of Medicine 1 (2).DOI:10.15347/wjm/2014.010. ISSN 2002-4436. - Arriba L, Hernández G. (2016). Xerostomia, hyposalivation, and salivary flow in Own work diabetes patients. Journal of Diabetes Research, 2016, pp.1-15. 37. Burkhart NW. Bulimia: Decreasing the damage to the enamel. RDH website. 16. Bretz W. (2002). Oral profiles of bulimic women: diagnosis and management. https://www.rdhmag.com/articles/print/volume-31/issue-1/columns/bulimia- What is the evidence? Journal of Evidence Based Dental Practice, 2(4), decreasing-the-damage-to-enamel.html. Published January 1, 2011. Accessed pp.267-272. March 5, 2019. 17. Clarke A. (2012). Eating disorders and your mouth health. Tribune 242, pp. http://www.tribune242.com/news/2012/oct/30/ Eating-disorders-and-your-mouth-health/jh. ALISA COOPER, DC, is a chiropractor, clinical nutritionist, 18. Rommel N, Rohleder N, Koerdt S, Wagenpfeil S, Härtel-Petri R, Wolff K, Kesting and certified Emotional Freedom Techniques practitioner with M. (2016). Sympathomimetic effects of chronic methamphetamine abuse on more than 25 years’ experience helping others achieve and oral health: a cross-sectional study. BMC Oral Health, 16(1). maintain optimal health and wellbeing. Dr. Cooper’s 19. The National Alliance of Advocates for Buprenorphine Treatment. Common informative presentations, books, articles and blogs empower buprenorphine side effects: headache, constipation, dry mouth. (2018). and educate others on various topics and trends in health Available at: https://www.naabt.org/faq_answers.cfm?ID=3. Accessed Jul. 31, care today. Dr. Cooper maintains a private practice and 2018. freelance writing career. 20. Veitz-Keenan A, Ferraiolo D. (2018). Cannabis use and xerostomia. [online] Dimensions of Dental Health. Available at: http://www.dimensions of dental hygiene.com/2011/11_November/features/cannabis_Use_and_Xerostomia. aspx. Accessed Jul. 31, 2018. 21. Gurvits G, Tan A. (2013). Burning mouth syndrome. World Journal of Gastroenterology, [online] 19(5). Available at: https://www.ncbi.nlm.nih.gov/

8 www.DentalAcademyOfCE.com ONLINE COMPLETION QUICK ACCESS CODE 15337 Use this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

QUESTIONS

1. The term “xerostomia” refers to which 7. Which is a function of saliva? 13. How many medications are known to of the following? a. Lubrication cause xerostomia? a. The subjective feeling of having a dry b. Digestion a. Over 400 mouth c. Protection b. Over 300 b. An objective decrease in saliva d. All of the above c. Over 200 c. An increase in saliva resulting in drooling d. Over 100 d. Both A and B 8. Which of the following statements is false? 14. What percentage of people taking 2. Who is most likely to experience a. The normal pH of saliva is 5-6 more than seven medications experi- xerostomia? b. Saliva helps maintain the oral microbiome ence xerostomia? a. Young females c. Saliva can be instrumental in preventing a. 17% b. Elderly females dental caries b. 34% c. Young males d. Taste sensation is related to adequate c. 50% d. Elderly males amount and composition of saliva d. 67%

3. What percentage of the population 9. Patients with xerostomia may com- 15. Which of the following statements is suffers from xerostomia? plain of: false? a. 10% a. Mild discomfort a. Radiation damage to salivary glands may b. 20% b. Significant pain and dysfunction be permanent c. 30% c. Burning sensations in the oral cavity b. Salivary gland tumors are common d. 40% d. All of the above c. Salivary gland damage affects approximately 50% of patients in the first week of 4. The world’s geriatric population is: 10. Which term describes an abnormal radiotherapy for head and neck cancers a. Increasing taste sensation? d. Salivary glands are superficially located b. Decreasing a. Dysphagia anatomical structures c. Staying about the same b. Dysgeusia d. Not relevant to the topic of xerostomia c. Cheilitis 16. Which of the following statements d. Glossodynia about Sjögren’s syndrome is true? 5. Which is not a common cause of xero- a. Its etiology is well known stomia in seniors? 11. Which is not characteristic of b. It affects more men than women by a ratio a. Polypharmacy xerostomia? of 9:1 b. Aging a. Sticky saliva c. Xerostomia in these patients is often severe c. Anxiety b. Oral malodor d. It targets only the oral cavity d. Systemic disease c. Dysphagia d. Insensitivity to spicy foods 17. Which of the following is not a com- 6. Which of the following is a constitu- mon cause of xerostomia? ent of saliva? 12. The most common cause of xerosto- a. Smoking a. Buffering agents mia is b. Geographic location b. Minerals a. Aging c. Depression and anxiety c. Both A and B b. Radiotherapy for head and neck cancers d. Excessive alcohol intake d. None of the above c. Medication d. Systemic disease

www.DentalAcademyOfCE.com 9 ONLINE COMPLETION QUICK ACCESS CODE 15337 Use this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

QUESTIONS

18. Dental professionals treating patients 23. If used on a regular basis, which of the 28. Which of the following is tantamount with bulimia may encounter which of following beverages would be least to preventing complications seen the following? likely to contribute to a dry mouth with xerostomia? a. Dental caries condition? a. Vigilant oral care b. Severe tooth erosion a. Margarita b. Frequent dental checkups c. Psychological conflict b. Cappuccino c. Healthy lifestyle choices d. All of the above c. Coca-Cola d. All of the above d. Coconut water 19. Which of the following statements is 29. Which of these statements about false? 24. When medications are the cause of xerostomia is false? a. Opiates cause constipation and xerostomia xerostomia, which of the following a. Xerostomia is a common condition with b. Marijuana’s effects on the oral cavity are strategies should be initiated? potentially devastating consequences temporary a. Search for an alternate medication b. Dental professionals can have a positive c. Methamphetamines stimulate the sympa- b. Reduce the dosage impact on xerostomia patients thetic nervous system c. Take the medication in divided doses c. There are few treatment options and d. Dentists treat oral complications of d. All of the above resources available for patients with addiction xerostomia 25. Which of the following statements d. The treatment of severe xerostomia may 20. Which of the following statements is about sialagogues is false? require an interdisciplinary approach true about burning mouth syndrome? a. Sialagogues treat anxiety and depression a. It presently affects half a million Americans b. Cevimeline and pilocarpine are sialagogues 30. Which statement is true concerning b. It is primarily a psychiatric disorder c. Sialagogues require some degree of func- popular over-the-counter products c. It commonly affects postmenopausal tional salivary gland tissue for treating xerostomia? women d. Sialagogues may cause unwanted side a. XyliMelts, Biotène, Xlear, Spry, CloSYS, d. All BMS patients suffer from xerostomia effects Hydris, and Vega Oral Care Solutions are all viable options 21. The initial approach to treating xero- 26. Which of the following is not recom- b. Dental professionals can introduce stomia commonly begins with: mended for addressing symptoms of patients to safe, effective oral care products a. Medication xerostomia? c. Patients are likely to appreciate sugges- b. Electrostimulation a. Chewing gum sweetened with xylitol tions and samples c. Acupuncture b. Alcohol-based mouthwash d. All of the above d. Lifestyle changes c. Toothpaste containing fluoride d. Adherent oral disks 22. Which of the following would be the worst food choice for someone with 27. Which of these nonmedical modali- xerostomia? ties for treating xerostomia warrants a. An arugula and beet salad further research? b. A fruit salad a. Hyperbaric oxygen treatments c. A freshly baked scone b. Traditional acupuncture d. A vegetable crudité c. Oil pulling d. All of the above

10 www.DentalAcademyOfCE.com PUBLICATION DATE: APRIL 2019 ANSWER SHEET EXPIRATION DATE: MARCH 2022 Xerostomia: Looking with fresh eyes to reduce dry mouth

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681 If not taking online, mail completed answer sheet to EDUCATIONAL OBJECTIVES PennWell Corp. Attn: Dental Division, 1. Understand the etiology of xerostomia 1421 S. Sheridan Rd., Tulsa, OK, 74112 2. Identify the signs and symptoms of xerostomia or fax to: 918-212-9037 3. Compare treatments for xerostomia For IMMEDIATE results, 4. Educate patients about xerostomia and offer compassionate support go to www.DentalAcademyOfCE.com to take tests online. 5. Recommend safe, effective products to help patients manage the condition at home QUICK ACCESS CODE 15337 Answer sheets can be faxed with credit card payment to COURSE EVALUATION 918-212-9037. 1. Were the individual course objectives met? Payment of $59.00 is enclosed. Objective #1: Yes No Objective #2: Yes No (Checks and credit cards are accepted.)

Objective #3: Yes No Objective #4: Yes No If paying by credit card, please complete the following: MC Visa AmEx Discover Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Acct. Number: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. Date: ______

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4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 1. 16. 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 2. 17. 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 3. 18. 7. Was the overall administration of the course effective? 5 4 3 2 1 0 4. 19. 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 5. 20. 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 6. 21.

10. Do you feel that the references were adequate? Yes No 7. 22.

11. Would you participate in a similar program on a different topic? Yes No 8. 23. 9. 24. 12. If any of the continuing education questions were unclear or ambiguous, please list them. ______10. 25. 11. 26. 13. Was there any subject matter you found confusing? Please describe. ______12. 27. 13. 28. 14. How long did it take you to complete this course? ______14. 29.

15. What additional continuing dental education topics would you like to see? 15. 30. ______AGD Code 730

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK PROVIDER INFORMATION RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental PennWell maintains records of your successful completion of any exam for a minimum of six years. survey included with the course. Please e-mail all questions to: [email protected]. association to assist dental professionals in identifying quality providers of continuing dental Please contact our offices for a copy of your continuing education credits report. This report, which will education. ADA CERP does not approve or endorse individual courses or instructors, nor does it list all credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS imply acceptance of credit hours by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Completing a single continuing education course does not provide enough information to give Participants will receive confirmation of passing by receipt of a verification form. Verification of Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at the participant the feeling that s/he is an expert in the field related to the course topic. It is a Participation forms will be mailed within two weeks after taking an examination. www.ada.org/cotocerp/ combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider by the All participants scoring at least 70% on the examination will receive a verification form verifying Academy of General Dentistry. The formal continuing dental education programs of this program CANCELLATION/REFUND POLICY 3 CE credits. The formal continuing education program of this sponsor is accepted by the AGD provider are accepted by the AGD for Fellowship, Mastership and membership maintenance Any participant who is not 100% satisfied with this course can request a full refund by contacting for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD PennWell in writing. Participants are urged to contact their state dental boards for continuing education requirements. endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider PennWell is a California Provider. The California Provider number is 4527. The cost for courses ID# 320452 IMAGE AUTHENTICITY ranges from $20.00 to $110.00. The images provided and included in this course have not been altered.

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