Adult Oral Health Clinical Case #1

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Question 1 of 3

1. Question
Mrs. Pederson is a 74 year old who presents for a routine blood pressure follow up visit. Her blood pressure is well controlled, but on review of systems she reports dry mouth of several years duration that has acutely worsened over the past 2 months. She quit smoking after she developed thyroid cancer that required surgery and neck radiation for cure. She has been drinking more water than usual, but it only improves her symptoms for a few minutes. She drinks wine with dinner and sometimes before bed for insomnia. On physical examination this is the appearance of her tongue:

Joanna Douglass, BDS, DDS

All of the following are likely contributing to Mrs. Pederson’s xerostomia (the sensation of dry mouth) except:
- The aging process
- Antihypertensive medications Many medications, including antihypertensives, can cause xerostomia. Diuretics are well known for this effect, but angiotensin converting enzyme (ACE) inhibitors, beta blockers and calcium channel blockers have also been associated with xerostomia.
- Alcohol use Alcohol consumption and use of tobacco products can both reduce salivary production and cause xerostomia.
- Head and neck radiation Head and neck radiation causes xerostomia acutely by inducing inflammation in the salivary glands that reduces salivary flow. Chronic fibrosis typically follows and further worsens symptoms.
- Sedative medications Sedative medications may be used by patients with insomnia. Many of these medications, including benzodiazepines and zolpidem, can cause dry mouth.
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Question 2 of 3

2. Question
Mrs. Pederson’s active medical problems include Hypertension, Type 2 Diabetes Mellitus, and Glaucoma. Her past history is remarkable for treated thyroid cancer, seasonal allergies, and intermittent insomnia. She smoked when she was younger, but quit 30 years ago. She is widowed and a retired administrative assistant. She enjoys a glass of wine about five times a week with dinner and walks daily for exercise.

Her medications include:
- lisinopril/HCTZ 10/25 mg orally once daily
- metformin 1000 mg orally twice daily
- aspirin 81 mg orally once daily
- zolpidem 10 mg orally at bedtime approximately twice per week
- diphenhydramine 25 mg orally as needed for allergy symptoms in the spring and fall
- latanoprost ophthalmic drops daily (topical prostaglandin analog for closed angle glaucoma treatment)
Based on the information provided above, which of the following scenarios would most likely contribute to Mrs. Pederson’s xerostomia?
- She began regularly using lemon candy drops to improve the smell of her breath. Both lemon and candies stimulate saliva production. If Mrs. Pederson were regularly using lemon candy drops, her symptoms of dry mouth should actually improve rather than worsen.
- She has been taking zolpidem nightly for worsening insomnia following the recent death of her favorite cousin.
- She had a recent upper respiratory infection and sore throat. Upper respiratory infections increase salivation, so her symptoms of dry mouth should actually improve rather than worsen.
- Due to the onset of winter she has not required any diphenhydramine for her allergies in the past 2 months. Antihistamines typically worsen xerostomia. Decreased use should lead to an improvement in symptoms rather than worsening.
- She has stopped drinking wine with dinner recently due to problems with heartburn. Alcohol can contribute to dry mouth through a local drying effect and systemic diuresis. Decreased use should lead to an improvement in symptoms rather than worsening.
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Question 3 of 3

3. Question
Mrs. Pederson reduces her alcohol intake and stops taking diphenhydramine and zolpidem. She understands the need for her antihypertensive and diabetic medications and will continue to take those as directed. After these changes her dry mouth improves to some degree, but is still symptomatic. She inquires what else she can do to improve her symptoms.

Which of the following interventions would be contraindicated for Mrs. Pederson?
- Use of an over-the-counter saliva substitute Saliva substitutes are of clear benefit in reducing the symptoms of dry mouth. However, they do need to be reapplied frequently.
- Sucking sugarless candy during the day to promote saliva production Chewing gum or sucking candy stimulates the flow of saliva and reduces symptoms of xerostomia. However, frequent exposure of oral bacteria to dietary sugars will lead to dental caries, so only sugarless products should be used. Many patients find gum more effective than candy.
- Starting cevimeline in an effort to increase saliva production
- Switching to an electric toothbrush from a traditional one Electric toothbrushes have been shown to increase saliva production and may be useful for some individuals. Further, improved oral hygiene may decrease the risk of dental caries.
- Avoiding sugary and caffeinated drinks Caffeinated beverages have a local drying effect and should be avoided in patients with xerostomia. Sugary drinks will increase the likelihood of caries as described above.
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Adult Oral Health

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