Psychiatric patients’ oral health
Psychiatric patients’ oral health status often is poor. Several studies found that compared with the general population, patients who have severe, persistent mental illness are at higher risk to be missing teeth, schedule fewer visits to the dentist, and neglect oral hygiene.25-28 Periodontal disease also could be a problem in these patients.29 Although some evidence suggests mental illness may make patients less likely to go to the dentist, psychotropic medications also may contribute to their dental difficulties.
Screening for xerostomia
Simply advising patients of the problems related to xerostomia and asking several questions may help prevent pain and deterioration in function within the oral cavity (Table 1).14,30
You can perform a simple in-office assessment of the oral cavity by visual inspection and by placing a dry tongue blade against the inside of the cheek mucosa. If the blade sticks to the mucosa and a gentle tug is needed to lift it away, xerostomia may be present.30 Conversely, a healthy mouth will have a collection of saliva on the floor of the oral cavity, and pulling a tongue blade away from the inside of the cheek will not require any effort (Photos 4 and 5).
Table 1
Screening questions for xerostomia
| Does the amount of saliva in your mouth seem to have decreased? |
| Do you have any trouble swallowing, speaking, or eating dry foods? |
| Do you sip liquids more often to help you swallow? |
| Do you notice any dryness or cracking of your lips? |
| Do you have mouth sores or a burning feeling in the mouth? |
| When was the last time you saw your dentist? (Patients with xerostomia may need to see their dentist more frequently) |
| Are you aware of any halitosis (ie, mouth odor)? |
| Source: Reference 14 |
Photo 4
The arrow shows the normal appearance of saliva collecting on the floor of the mouth
Photo 5
This patient complained of dry mouth. Note the floor of the mouth is free of saliva (a). Decay is present (b), and the patient is missing posterior teeth (c). This patient was taking clonidine, metoprolol, hydrochlorothiazide, amlodipine, and irbesartan
Treatment options
Patients who have reduced salivary flow as a result of a medication may become so affected by dryness that their drug regimen may need to be changed. However, the greatest concern is for deteriorating oral health among patients who may be unaware xerostomia is occurring.31
Counsel patients who take medications that can affect their salivary function about the importance of seeing a dentist regularly, and provide referrals when appropriate. Depending upon the patient’s oral health, dentists recommend patients with xerostomia have their teeth cleaned/examined 3 or 4 times per year, rather than the 2 times per year allowed by third-party payers (ie, insurance companies). Also advise patients to be diligent in their oral hygiene practices, including flossing and brushing the teeth and tongue, and to avoid foods that are sticky and/or have high sucrose content (Table 2). Recommend using a toothpaste containing fluoride—preferably one free of sodium lauryl sulfate, which could contribute to mouth sores14—and drinking fluoridated water. Explain to patients that their dentist may recommend in-office high-fluoride applications, high-fluoride prescription toothpaste, and/or “mouth trays” that contain high fluoride gel. Tell patients to avoid cigarettes and caffeinated beverages, which can increase dryness. Alcohol use should be minimized and mouth rinses containing alcohol should not be used.
Many over-the-counter products are available to address xerostomia, including toothpastes, mouth rinses, and gels. Salivary substitutes—which are available as sprays, liquids, tablets, and swab sticks—imitate saliva and may provide a temporary reprieve from dryness. Although none of these products will cure dry mouth, they may help manage the condition. Advise patients to eat foods that stimulate saliva production, such as carrots, apples, and celery, and to chew sugarless gum and candies, which also will stimulate salivary flow.
The FDA has approved 2 prescription drugs for treating xerostomia: cevimeline and pilocarpine. Cevimeline is approved for treating dry mouth associated with Sjögren’s syndrome and pilocarpine is approved for treating dry mouth caused by head and neck radiation therapy; however, these medications’ role in treating dry mouth in psychiatric patients has not been investigated. Both agents are contraindicated in patients with narrow-angle glaucoma, uncontrolled asthma, or liver disease, and should be prescribed with caution for patients with cardiovascular disease, chronic respiratory conditions, or kidney disease.32