RENEW OR SUBSCRIBE TO PPM
Subscription is FREE for qualified healthcare professionals in the US.
9 Articles in Volume 9, Issue #2
Acupuncture for Fibromyalgia
Brain Atrophy with Chronic Pain: A Call for Enhanced Treatment
Evaluating Function/Impairment of Low Back Pain Using SEMG
Medication-induced Xerostomia Secondary to Pain Management
Neuroscience, Neurophilosophy, and Neuroethics of Pain, Pain Care, and Policy (N3P3)
Reducing Pain and Anxiety During Reduction of a Fracture
Successful Treatment of Intractable Pain
Treating Chronic Pain by Patient Empowerment
Treatment of Scapulohumeral Periarthritis and Post-traumatic Joint Pain

Medication-induced Xerostomia Secondary to Pain Management

Long-term pain management—with its usage of prescriptive medications—may have serious negative oral health side-effects including significant dental pathology, soft-tissue problems, and potential loss of dentition.

Orofacial pain management generally does not occur in a diagnostic vacuum. The patients we see generally have other somatic pain syndromes secondary to trauma, chronic disease or psyche and are being managed concurrently by other health professionals. These pain syndromes are generally managed with multiple pharmaceutical products by very skilled medical professionals. Unfortunately, these powerful medications have negative secondary side-effects. One of the most damaging is the medication-induced hyposalivation that occurs during the course of treatment. The xerostomic complaints from the patients appear to have no resolution. The hyposalivation condition results in a reduced production and quality of saliva with these changes ultimately resulting in the loss of dentition or a dentition that is severely damaged.

Xerostomic Syndrome

We listen to patients’ complaints of xerostomia and note that many healthcare professionals suggest they drink more water. Not understanding the xerostomic syndrome results in mismanagement of the patient. Xerostomia is defined here as the subjective sensation and the objective diagnosis of persistent oral dryness and is generally described by patients in these terms. A subset of these patients may also report a burning mouth, mucosa, or tongue. Investigators have found that xerostomic complaints are experienced when a previously normal salivary flow rate is reduced by 40% to 50%.1

In the year 2000, the NIH published “The Surgeon General’s Report of Oral Health in America,” which concluded that: “The main function of saliva is not—as is commonly believed—to aid in digestion, but to protect the integrity of the oral tissues. The ability of saliva to limit the growth of pathogens—and in some instances even preventing them from establishing a niche in the biofilm community in the first place—is a major determinant of general, as well as oral, health. When salivary flow is compromised, the gateway to the body can open wide to local as well as to systemic pathogens.”2

“Saliva is indispensable for maintaining oral health. It lubricates the oral mucosa, promotes remineralization of the teeth, and protects the mouth against infections caused by pathogenic microorganisms. Although it is the main oral tissue protective fluid, its chief importance to the individual’s welfare is generally perceived only when the salivary flow rate decreases.”3

Caries Management by Risk Assessment

The February and March 2003 issues of the Journal of the California Dental Association (CDA) were dedicated to reviewing the scientific basis for the most current approach to caries management using risk assessment protocols for diagnosis, treatment and prevention, including non-surgical means for repairing—or remineralizing—tooth structure. The science, Caries Management by Risk Assessment (CAMBRA), was introduced and culminated with a consensus statement of national experts. Production of risk assessment criteria and forms for clinicians to use in practice was published for the profession. These latest CAMBRA guidelines were published in the CDA journal in 2007.4,5

Since CAMBRA is now well-documented in the literature, clinicians are increasingly using these guidelines in their practices to the benefit of their patients. CAMBRA has become “Standard of Care” regarding the issues of xerostomia, caries, and oral health. These xerostomic issues relate directly to quality and production of saliva and also to the issue of “medication-induced and maintained xerostomia.” Much of the medical and dental management of caries has historically been focused on the restoration of dental caries and symptoms of the transmissible bacterial infection. The change in biofilm, which occurs in the xerostomic environment, becomes the pathological agent regarding dental, periodontal, and mucosal pathologies. Both risk-assessment and professional interventions are based on the concept of altering the caries balance. We are using “The Caries Balance” model, where pathological factors of bacteria, absence of healthy saliva, and poor dietary habits (i.e., frequent ingestion of fermentable carbohydrates) battle protective factors such as saliva and sealants, antibacterials, fluoride. and an effective diet.6

Role of Saliva in Oral Health

To reinforce the CAMBRA guidelines it is noted that saliva plays such a significant role in a patient’s oral health that the American Dental Association published a forty-four page JADA “Special Supplement” report in May 2008.7 This report addresses composition, biofilm, dental caries, medication side-effects, flow-patterns, integrity of enamel and dentition, and additional issues. It also discusses saliva’s critical role in the preservation of oropharyngeal health. U.S. researchers have identified all 1,116 unique proteins found in human salivary glands and human saliva. It is also notable that patients who experience dry mouth (xerostomia) and diminished salivary output are at high-risk for gastritis, hoarseness, oral, and other pharyngeal disorders.

Xerostomic salivary changes can also play another role. In addition to the major salivary glands being affected, all of the accessory or minor salivary glands are affected. These are located in the oral mucosa, including the lip, cheeks, tongue, floor of the mouth, posterior hard palate, uvula, molar, retromolar, and peritonsillar regions. These glands must function normally in order to maintain a normal oral-health status. There are no salivary glands on the gums or on the anterior part of the hard palate. The well-known functions of normal saliva include:

 

 

  • maintaining a neutral oral pH through various buffer systems,
  • It’s also important to mention the necessity for the flushing mechanism of the esophagus for protection against stomach acid. Therefore, the loss of saliva is thought to be associated with a loss of “protection.”

    “Objective signs of dry mouth result from one or more factors disrupting the quantity or quality of salivary flow. This hyposalivation can result in oral sequela, such as mucosal burning and discomfort, many of the teeth being sensitive or just aching...”

    Functional and Structural Causes of Dry Mouth

    Most chronic pain and fibromyalgia patients who are being treated by physicians with prescriptive medications complain about dry mouth (xerostomia). The factors that lead to hyposalivation and the resulting xerostomia may be either functional or structural. The functional factors include chronic anxiety states, prescriptive and non-prescriptive medications, and dehydration. Structural causes of xerostomia include Sjogren’s Syndrome, sarcoidosis, post-irradiation damage, developmental anomalies and, possibly, diabetes mellitus. However, these factors tend to be in the minority. Absent structural causes, the vast majority of xerostomic conditions are either anxiety or prescriptive-medication induced.9 “Medications are the most common cause of dry mouth. More than 400 medications (both prescribed and over-the-counter) list dry-mouth as a potential adverse effect.”8 Several researchers have indicated that the prevalence of xerostomia is positively related to the total number of drugs used, whether xerogenic or not.10

    Objective signs of dry mouth result from one or more factors disrupting the quantity or quality of salivary flow. This hyposalivation can result in oral sequela, such as mucosal burning and discomfort, many of the teeth being sensitive or just aching, difficulties in mastication and swallowing, dental caries, aggravation of gastritis-GERD, and fungal infections. In fact, active gastritis-GERD can cause severe erosion of the dentition within a few months. Some causes of xerostomia even include the use of antidepressant drugs, and the use of cardiovascular medication.11 The above-referenced problems are frequently under-diagnosed conditions but, nevertheless, affect the patient very negatively. We have seen pain management patients on opioids and other multiple prescriptive drugs (polypharmacy) present with dental damage resulting in up to $80,000 in rehabilitation expenses requiring dental implants and associated prostheses. Many times, the dental caries resulting from medication-induced and maintained hyposalivation is unrestorable and is generally iatrogenic in causation.

    “Many dentists or physicians tend to rely on the patient’s complaint of xerostomia to diagnose hyposalivation. Unfortunately, a subjective complaint of xerostomia often does not correlate with objective findings of reduced salivary flow rate.12 As noted, “The subjective symptomatology of xerostomia does not become apparent until unstimulated salivary volume falls below 50 percent. With the decrease in salivary volume, patients will develop increased difficulty in swallowing, taste alterations, oral burning, lip dryness and, most importantly, dental deterioration. Extensive caries can be anticipated with the loss of saliva’s buffering, cleansing, and antibacterial capacities.”13

    Preventive Care Program

    “Certain medications such as psycho-pharmaceutical drugs reduce the flow rate of saliva and may affect caries risk.”14 Medications such as the SSRIs and other contemporary antidepressants are psycho-pharmaceutical drugs and fall into this group. When these medications are being prescribed, and are medically necessary in the opinion of the prescribing doctor, the prescriber also needs to know that these medications have documented negative dental side-effects which must be managed consistent with ‘Standard of Care.’

    In an article entitled “Antidepressant use in Psychiatry and Medicine,”15 the commentary notes the importance of the physician and dentist being knowledgeable about medications that increase the risk of xerostomia and the need for initiation of an intensive preventive dentistry program. This preventive care program should include patient education in maintaining home hygiene practices, increased fluid intake, fluoride applications, creation of beneficial biofilm changes, use of therapeutic agents that stimulate salivation, use of antimicrobial rinses, and regularly-scheduled dental examinations.

    In light of this background, one can see why it is so important to institute the appropriate ‘Standard of Care’ treatment as documented in the August 2006 JADA. It is our opinion that CAMBRA guidelines should be initiated when “pain management” is initiated. These guidelines imply referral to a dentist who is knowledgeable in xerostomic issues. This ‘Standard of Care’ guideline resulted in the recommendation that dental examinations and cleanings for the high risk xerostomic patient be rendered up to every three months. Of course, this must be determined by the patient’s dentist but evidenced-based publications support frequent and regular preventive care. “Studies have shown that patients at risk of developing caries and other oral pathologies due to hyposalivation can be treated successfully by exposing them to acidogenic biofilm modifying agents, fluorides, and other professional modalities. As the polypharmacy-induced caries risk increases, patients should be exposed to fluoride more frequently and at higher doses than solely from dentifrice or both.”16

    It is also noteworthy to mention that “Since nature’s buffer against cavities and saliva is decreased during the night, medications given before bed can do a great deal of damage…”17 It is interesting to note that patients’ salivary flow rates may decrease simply in proportion to the number of prescription drugs they are taking. Since most fibromyalgia and pain-management patients are taking numerous daily prescriptive medications, they are all at high-risk for significant dental disease or loss of dentition and which can be considered a secondary or derivative injury. Patient ‘Informed Consent’ obtained by the prescriber of pain medications is ‘Standard of Care.’

    Conclusion

    Usage of prescriptive medications causes significant dental pathology and soft-tissue problems, including loss of the dentition. From the dental perspective, prevention is foremost as it relates to medication-induced and maintained hyposalivation (xerostomic) issues. Failure to pay attention to these issues will only further complicate the lives of patients undergoing chronic pain management.

    • providing local antimicrobial activity through enzymes, immunoglobulin A, histatins, and • serving as a solvent for the taste mechanism.8

    • supporting ongoing remineralization of teeth by providing a reservoir of calcium and phosphate ions,
    • coating the oral mucosa and teeth to protect them against harmful substances,
    • lubricating the mouth to facilitate chewing, swallowing, and speech,
    Last updated on: February 23, 2011
    close X
    SHOW MAIN MENU
    SHOW SUB MENU