Day: July 13, 2009

Why Does He Have Such a Dry Mouth?

Patient Presentation
An 11-year-old male came to clinic for his health supervision visit. He had a history of cerebral palsy, severe mental retardation, epilepsy, seasonal allergic rhinitis and various orthopaedic problems.
He recently had his anti-convulsants changed because of increased seizures and since the change his seizures had been well controlled with only one seizure every other day.
His mother had also re-started his systemic medication for his seasonal allergic rhinitis recently and noted that usually he did a lot of mouth breathing too.
She was concerned because she had noticed that he recently had and more thick saliva and a drier mouth than he usually did.

The pertinent physical exam showed a small male who was wheelchair bound, with obvious mental retardation but was alert to his environment. His mother was able to understand many of his wants and needs but the healthcare provider could not.
He had a head circumference of 10%. He did not appear dehydrated.
His nose had slightly swollen nasal turbinates.
His mouth had thick, dried saliva at the corners and a general dry mouth without ulcerations. There were two obvious caries in the lower posterior right molars.
He had hypertonia in the upper and lower extremities.
Skin examination showed some very minor irritation at the edges of his ankle-foot orthoses and at the edge of a right wrist splint.

The diagnosis of a school-ager with multiple medical problems and xerostomia was made.
The health care provider told the mother that the most common reason for the increased dried secretions was the combination of the increased anti-convulsants and the institution of the anti-histamines, along with mouth breathing.
Since he was well controlled on these medications, the health care provider did not want to change the medication.
However, as the patient had obvious caries, she recommended to see the dentist who could treat the caries and provide guidance regarding a saliva substitute or other options.
The patient’s clinical course showed that the dentist fixed the caries, changed the dental routine to include a fluoride mouth wash and use of a mouth moisturizing gel. His mother was happy with the results.

Discussion
Saliva is produced mainly from the submandibular salivary glands (70-75%) and the parotid gland (20-25%). It functions to protect the mouth, aid digestion, maintain tooth integrity and facilitate chewing, swallowing and speech.

Dry mouth or xerostomia especially in children is usually a temporary condition often associated with dehydration or mouth breathing. But it can be a more chronic condition that can affect quality of life and overall health. Patients with chronic xerostomia may stop eating certain dry or sticky foods which may lead to malnutrition. It can also change taste, and impair chewing, swallowing, and swallowing. It can also cause fissures in the skin or oral mucosa and contribute to dental caries and other oral infections.
Children with multiple medical problems, especially those using multiple medications are at high-risk for xerostomia.

Learning Point
Causes of xerostomia include:

  • Dehydration – one of the most common causes in children
  • Mouth breathing
  • Chemotherapy
  • Radiation
  • Tobacco use
  • Salivary gland removal
  • Diseases
    • Alzheimer’s disease
    • Cystic Fibrosis
    • Diabetes
    • Graft-vs-Host Disease
    • Hepatitis C
    • HIV/AIDS
    • Mikulicz syndrome
    • Mumps
    • Parkinson’s disease
    • Psychiatric symptom
    • Rheumatoid arthritis
    • Sjogren’s syndrome
    • Stroke
    • Thyroid disease
  • Medication side effects – the most common cause of xerostomia in dental practices
    • Acne medications
    • Anorexiant
    • Anti-anxiety medication
    • Anti-cholinergics
    • Anti-depressants including tricyclic and selective serotonin reuptake inhibitors
    • Anti-convulsants
    • Anti-emetics
    • Anti-histamines
    • Anti-hypertensive
    • Anti-obesity
    • Anti-parkinsonian
    • Anti-psychotics
    • Bronchodilators
    • Decongestants
    • Diuretics
    • Muscle relaxants
    • Narcotics
    • Sedatives
    • Urinary incontinence medications

Questions for Further Discussion
1. What causes hypersalivation?
2. List the risk factors for dental caries?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Mouth Disorders and Medicines.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:177-78.

Cassolato SF, Turnbull RS. Xerostomia: clinical aspects and treatment. Gerodontology. 2003 Dec;20(2):64-77.

Curzon ME, Preston AJ. Risk groups: nursing bottle caries/caries in the elderly. Caries Res. 2004;38 Suppl 1:24-33.

Nokta M. Oral manifestations associated with HIV infection. Curr HIV/AIDS Rep. 2008 Feb;5(1):5-12.

MedicineNet.com. Dry Mouth. WebMD.
Available from the Internet at http://www.medicinenet.com/dry_mouth/article.htm (rev. 2009, cited 6/24/09).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital