4 Providing Information to Referring Physicians and Patients |
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Table 4.11 (continued)
In patients with clinically visible salivary secretion, this is most conveniently managed with systemic fluconazole, one 100 mg tablet daily for 2Ð4 weeks, and monitoring the patient for the treatment endpoints described below.
The patient is informed that if there is no signiÞcant resolution of symptoms within 2Ð4 weeks, then they may be switched to a topical form of medication.
Patients with severe chronic hyposalivation and lacking visible salivary secretion usually require topical forms of anti-fungal drugs that do not contain sucrose or glucose, because they must be administered for periods of weeks or months.
These topical forms are necessary because systemically administered drugs may not reach the mouth of such patients in therapeutically adequate amounts via the saliva.
Topical drugs must not increase a patientÕs risk for dental caries but, currently, all commercially packaged ÒoralÓ anti-fungal drugs contain glucose or sucrose that presents a signiÞcant risk of supporting caries development when used in these patients.
•Generally, the best topical anti-fungal drug for use in patients with severe hyposalivation and remaining natural teeth is nystatin vaginal tablets, which contain lactose, but not sucrose or glucose.
•They must be dissolved slowly in the mouth for 15Ð20 min, two or three times/day.
•Such patients will need frequent sips of water to allow the tablet to dissolve in that time.
•For patients wearing partial or complete dentures, additional instructions and treatment are needed:
1.Dentures must be removed from the mouth before applying the anti-fungal drug.
2.Dentures must be disinfected by soaking overnight in a substance compatible with the denture material (e.g., 1% sodium hypochlorite for dentures without exposed metal or benzalkonium chloride diluted 1:750 in water for dentures with exposed metal) and rinsed carefully before reinserting in the mouth.
3.Nystatin topical powder may be applied in a thin Þlm onto the moistened Þtting surface of a denture when it is reinserted in the mouth.
•Treatment endpoint: Treatment should continue until the clinician has observed resolution of all the mucosal erythema, return of Þliform papillae to the dorsal tongue, and resolution of associated oral symptoms (i.e., burning, intolerance to spicy foods).
•Angular cheilitis: The presence of angular cheilitis almost always indicates concurrent intra-oral candidiasis.
◦ Angular cheilitis can be treated by nystatin or clotrimazole cream, but in most cases it should not be used without concurrently treating the intra-oral infection, as described above.
• Recurrence: After treatment is completed, recurrence is fairly common and the patient must be re-treated as described above.
◦After one recurrence, re-treatment should be immediately followed by maintenance therapy (e.g., continued use of half of a nystatin vaginal tablet slowly dissolved in the mouth each day, indeÞnitely).
◦The patient with a chronic infection should be counseled on the possibility of re-infection with a previously used lipstick, lip balm, toothbrush, utensil, or other activity (e.g., oral sexual copulation).
oral membranes and tongue glide past each other. We list some guidelines for these problems below.
Table 4.12 outlines hints for dry and painful mouth.
Physicians need to be alert to medications that have anti-cholinergic side effects that exacerbate dry mouth symptoms. These drugs may include agents such as amitriptyline used for ÒÞbromyalgiaÓ or over-the-counter sleep remedies that contain anti-cholinergic drugs such as benadryl. Many anti-hypertensive medications
and anti-seizure medications used for treatment of neuropathy may exacerbate dry mouth symptoms (Table 4.13, drugs with anti-cholinergic effects).
4.8Summary
Symptomatic treatment of SS patients involves a wide spectrum of medical and oral medicine specialists. The issues are often Òquality of lifeÓ
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Table 4.12 Burning mouth and common mouth lubricants
A. Burning mouth syndrome
In some patients, the symptoms of burning mouth are disproportionate to the amount of observed dryness. In these patients, low-grade oral yeast infection must be ruled out. In particular, look under the dentures for erythematous candida infection.
In other patients, ÒburningÓ mouth syndrome may represent a local neuropathy. The use of Neurontin may be helpful in some patients. Other options include the topical use of clonazepam (0.5 mg dissolved in 2 ml water) and it is used as a mouth rinse twice daily.
B. Common products used for dry mouth
Biotene mouth rinse
Biotene mouth spray
Biotene toothpaste
Biotene gum
Oral balance gel (especially at nighttime)
Oasis oral spray
Mouth Kote oral spray
Rain Spy dry mouth spray
Thayer dry mouth spray
FarleyÕs throat spray
Orahealth mints
Numoisyn lozenges
SalivaSure lozenges
These products are readily available at many retail stores and can be purchased online at sites such as www.amazon.com.
Table 4.13 Drugs associated with decreased salivary secretion and increased oral dryness
I. Blood pressure medications
A.α-Adrenergic blockers (clonidine, Catapres)
B.β-Adrenergic blockers (Inderal, Tenormin)
C.Combined α,β-blockers (Labetalol)
II. Anti-depressants (also used for neuropathy and other causes)
A.Amitriptyline (Elavil)
B.Nortriptyline (Pamelor)
C.Desipramine
D.Parnate, Nardil (MAO inhibitors)
E.Mellaril (dopamine blocker)
III. Muscle spasm
A.Flexeril
B.Robaxin
C.Baclofen
IV. Urologic drugs
A.Ditropan, Detrol
B.Yohimbe
V. Cardiac
A. Norpace
4 Providing Information to Referring Physicians and Patients |
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Table 4.13 (continued)
VI. ParkinsonÕs
A.Sinemet (carbidopa-Levodopa)
B.Requip (robinirole)
VII. Decongestants and sleeping aids (many are over the counter)
A.Chlortrimeton
B.Pseudofed (pseudoephedirne)
C.Atarax, Benadryl
rather than Òlife threatening.Ó In the limited time available for the patient at the time of their revisit, there is often not available time to deal with Òquality of lifeÓ treatments such as dry eyes or dry mouth. Furthermore, it is assumed that Òanother specialistÓ will handle that problem. As a result, the patient is left without speciÞc approaches to their symptomatic problems. This chapter provides a series of tables that might be provided to patients and their referring physicians.
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Part II
Classification Criteria and Disease Status
Activity, Histology of Salivary Gland
Biopsy, and Imaging