Xerostomia and Dysphagia - American Speech-Language

Xerostomia and Dysphagia
Who, How, Why, and What to Do
By
Cynthia Armstrong, M.S., CCC-SLP
What is Xerostomia?
Xero—”dry”
Stoma—”mouth”
Xerostomia
Reduction of saliva
 Imbalance of components of saliva

Saliva

Clear, watery fluid secreted from the
sublingual, parotid, submandibular,
and various minor salivary glands
throughout the mouth.
Components of Saliva

Protein secretions
◦ Digestive enzyme
◦ Lubricating aid





Potassium ions
Bicarbonate ions
Sodium ions
Chloride ions
Bacterial and fungal-fighting agents
◦
◦
◦
◦
Immunoglobulins
Lactoferrin
Thiocyanate
Lysozyme
Innervation of Salivary Glands

Parasympathetic glands
◦ Watery secretions

Sympathetic glands
◦ Thicker secretions
**Imbalance of correct ratio of watery
secretions with thick secretions can cause
the feeling of dry mouth, when thicker
saliva predominates
Who is likely to experience
xerostomia?














People taking medications
Sjogren’s syndrome
People with laryngopharyngeal reflux
Mouth breathers
Cancer patients
Diabetics
Smokers
People who drink caffeine
People who drink alcohol
People with vasculitis
HIV patients
Patients with thyroid issues
People with arthritis
Aged population
Xerostomia

1 in 4.5 people experience
xerostomia!
Medications That Cause Dry
Mouth
Antihistamines
 Diuretics
 Blood Pressure Medicines
 Muscle Relaxers
 Antidepressants
 Analgesics
 Sedatives
 Anti-Parkinson drugs
 Bronchial Dilators

Diseases (or their treatment) that
may cause dry mouth

Sjogren’s syndrome
◦ 3% of people over the age of 50 may have Sjogren’s syndrome.
90% of them are women. Lymphocytic infiltration of the salivary
glands. Autoimmune disease.

Cancer treatment
◦ Radiation treatment can cause an inflammatory reaction or can
be caused by fibrosis of the tissue, several months to several
years later. Atrophy of the glands may also cause loss of saliva
secretion.
◦ Chemotherapy drugs may disrupt the composition of the saliva,
making it thicker than it should be.

HIV/AIDS
◦ Can cause enlargement of the parotid or submandibular glands,
resulting in xerostomia.

Diabetes, arthritis, vasculitis, cystic fibrosis, scleroderma,
hypertension, thyroid dysfunction, cerebral palsy, Bell’s palsy,
end-stage renal disease, lupus
Drying Agents
Tobacco
 Alcohol

◦ Beverages
◦ Mouthwash
Caffeine
 Laryngopharyngeal reflux
 Mouth-breathing
 C-PAP

What does xerostomia have to
do with dysphagia? (WHY?)
◦ Reduced ability to chew
◦ Reduced ability to propel solids and pills thru the oral
and pharyngeal region.
◦ Changes in taste
◦ Oral sensitivity
◦ Reduced sensation
◦ Tooth decay/gum disorders/enamel changes
◦ Reduced digestion
◦ Other





Bad breath
Darker teeth
Tongue stickiness
Reduced ability to fight infections
Yeast growth
Reduced ability to chew
Xerostomia can make chewing painful
 Chewing stimulates saliva secretion

Xerostomia
Reduced
saliva
secretion
Vicious
cycle
Reduced
chewing
Mouth pain
Reduced ability to propel solids
and pills




MBS may not demonstrate this well due
to coating of oral and pharyngeal regions
with barium.
FEES is a better way to diagnose this
particular problem.
MBS with esophageal scan can show
how pills or solids become “stuck” in
esophagus.
Many patients report globus with this
problem even when the area has
cleared.
Pills may become “stuck” when
xerostomia is present
Changes in taste
Many people report significant
changes in taste as a result of dry
mouth
 Thrush is prevalent in patients with dry
mouth, and can result in significant
taste changes as well as in pain with
swallowing

Oral sensitivity
Temperatures
 Spicy
 Salty
 Acidic
 Sores in mouth from dryness
 Pain from thrush/yeast

Reduced sensation

Swallow is triggered by the sensation
of the bolus in the pharynx.
Xerostomia can lessen the ability to
sense the bolus, especially if it is
bland or of mild temperature.
Tooth decay/gum
disorders/enamel changes
Tooth decay
Radiation necrosis
Xerostomia and Thrush
Thrush/yeast overgrowth is common in patients with xerostomia.
Reduced digestion
Other issues resulting from
xerostomia





Bad breath
Darker teeth
Tongue stickiness
Reduced ability to fight infections
Yeast growth
What to do?
1.
Patients should be advised to drink
plenty of water
What to do?
2.
Medication
--Change medications, if possible, to a lessdrying substitute
--Use liquid medications that travel better
than pills
--Use coated pills
What to do?
3. Avoid drinking alcohol and using
alcohol-based mouthwash
Biotene mouthwash is an overthe-counter mouthwash that is
alcohol-free
What to do?
4.
Avoid smoking
What to do?
5. Reduce caffeine intake
What to do?

6. Stay away from sugary and/or
sticky foods
What to do?
7.
Avoid dry, crumbly foods
What to do?
8.
Alternate liquids and solids during
meals
What to do?
9. Use a humidifier
What to do?
10. Chew sugarless gum
What to do?
11. Hard candy (not mint)
What to do?
12. Saliva producing medications
Pilocarpine hydrochloride
Cevimeline hydrochloride
What to do?
13. Saliva substitutes or oral rinses
What to do?
14. Other agents to make oral cavity
“slick”
What to do?
15. Treat laryngopharyngeal reflux (LPR)
Symptoms of LPR are different from GERD
GERD = heartburn
LPR = throat clearing, globus, post nasal drip,
voice problems, coughing
Treatment:
Medication
Dietary changes
Exercise
Causes of Reflux

Body overproduces acid
◦
◦
◦
Occurs to everyone at one time or another
May or may not be stress related
Controlled by Proton-Pump Inhibitors



Eating acidic things
◦
Despite being on PPI’s, eating acidic things can give a person reflux





Nexium, Prilosec, Aciphex, Prevacid, Protonix
These must be taken every day for effectiveness!
Tomatoes
Citrus Fruits (Low acid orange juice better)
Soft Drinks
Milk (lactose-free or soy better)
Dysfunction of the lower esophageal sphincter (LES)
◦
Despite being on PPI’s or avoiding acidic things







◦
Overeating at a meal
Taking Muscle Relaxers
Alcohol
Smoking
Caffeine
Mints
General dysfunction of the LES
Nissen Fundoplication
What to do?
16. Acupuncture
What to do?
17. Electrical stimulation
Electrical stimulation study for
improving dry mouth in irradiated
patients
Xerostomia FEES
FEES before mineral oil
placement
Residue after initial swallow
with cracker
Mild pharyngeal residue
after 5 swallows
FEES after drop of mineral oil
Same patient, same cracker
but given after one drop of
mineral oil. One swallow only.
Questions?
Bibliography









Bartels, C., et al. (2011). “Xerostomia Information for Dentists.” Oral Cancer
Foundation website.
“Dry Mouth” (2011). NIH Publication No. 11-3174.
Liza Blumenfeld MA, CCC-SLP, et al (2006). Transcutaneous electrical stimulation
versus traditional dysphagia therapy: A nonconcurrent cohort study. Otolaryngology
- Head and Neck Surgery, Vol 135 (5) 754-757 .
Guimaraes, K (2009). American Journal of Respiratory and Critical Care Medicine,
vol 179: pp 962-966. 7-50.
Guggenheimer, M., et al (2003). “Xerostomia Etiology, Recognition, and
Treatment.” Journal of the American Dental Association, Vol 134: pp. 61-69.
Hamlet, S., et al (1997). “Mastication and Swallowing in Patients with
Postirradiation Xerostomia.” Journal of Radiation Oncology Biol Phys, Vol 37 (4):
pp 789-96.
Hoffman, M. (2008) “Nerve Pain and Nerve Damage: Symptoms and Causes.”
Web MD.
Lazarus, Cathy L., et. al (June 2009) “Effects of Chemoradiotherapy on Tongue
Function in Patients with Head and Neck Cancer.” Perspectives on Swallowing and
Swallowing Disorders (18) 55-60.
Logemann, J., et al (2001) “Effects of xerostomia on perception and performance of
swallow function.” Head and Neck, Vol 23 (4): pp 317-21.
Bibliography







Moore, P., et al (2001) “Type 1 Diabetes Mellitus, Xerostomia, and Salivary Flow
Rates.” Oral Surgery, vol. 92, 281-91.
Nagler, et al (1991) “Pilocarpine Hydrochloride Relieves Xerostomia in Chronic
Graft-Versus Host Disease: A Sialometrical Study.” Bone Marrow Transplant, Vol
23 (10): pp 1007-11.
Patanni, K., et al (2010) “Electrical Stimulation of Post-Irradiated Head and Neck
Squamous Cell Carcinoma to Improve Xerostomia.” Journal of the Louisiana State
Medical Society, vol 162: pp. 21-25.
Robbins, JoAnne, et. al (2008) “Swallowing and Dysphagia Rehabilitation:
Translating Principles of Neural Plasticity Into Clinicaly Oriented Evidence.” Journal
of Speech, Language,
Rosenthal, D., (2006) “Prevention and Treatment of Dysphagia and Aspiration after
Chemoradiation for Head and Neck Cancer.” Journal of Clinical Oncology, Vol 24
(17): pp 2636-43.
Rydholm, M., (1999) “Acupuncture for Patient in Hospital-based Home Care
Suffering from Xerostomia.” Journal of Palliative Care, vol 15(4): pp 20-23.
Stachler, R., et al (1994) “Swallowing of Bolus Types by Postsurgical Head and
Neck Cancer Patients.” Head and Neck, Vol 16 (5): pp 413-9.