An 86-year-old woman comes to the clinic due to mouth dryness that has led to oral soreness and difficulty tasting, swallowing, and speaking. The patient has a history of locally advanced squamous cell carcinoma of the mouth and recently underwent radiation therapy. Medical history also includes hypertension, diabetes, and depression. She currently takes lisinopril, oxycodone, long-acting morphine, citalopram, and insulin.
Vital signs are normal with no orthostasis. The patient's lips and oral mucosa appear dry. Oral hygiene is poor, and diffuse dental caries are present. The saliva appears stringy. The affected region of her face shows changes consistent with localized radiation therapy. The remainder of the physical examination is normal.
Which of the following is the best next step in management of this patient's symptoms?

Question

An 86-year-old woman comes to the clinic due to mouth dryness that has led to oral soreness and difficulty tasting, swallowing, and speaking.  The patient has a history of locally advanced squamous cell carcinoma of the mouth and recently underwent radiation therapy.  Medical history also includes hypertension, diabetes, and depression.  She currently takes lisinopril, oxycodone, long-acting morphine, citalopram, and insulin.
Vital signs are normal with no orthostasis.  The patient's lips and oral mucosa appear dry.  Oral hygiene is poor, and diffuse dental caries are present.  The saliva appears stringy.  The affected region of her face shows changes consistent with localized radiation therapy.  The remainder of the physical examination is normal.
Which of the following is the best next step in management of this patient's symptoms?

Quizplus · Accepted Answer

Xerostomia (dry mouth) occurs in approximately 80% of patients undergoing radiotherapy for head and neck cancer. Most cases are transient but permanent damage can occur with large radiation doses, especially if no parotid glands are spared (the parotid glands account for >75% of saliva production). Complications include oral pain, dental carries, oral infections, anorexia, and difficulty talking, chewing, and swallowing. The treatment of xerostomia is multifaceted and typically includes: Removing medications (if possible) that can worsen xerostomia, such as anticholinergics and antidepressantsNonpharmacologic interventions such as saline rinses, water-soluble mouth lubricants, regular dental care/surveillance, and frequent chewing (eg, sugarless gum) to mechanically stimulate salivationPharmacologic therapy using cholinergic medications (eg, pilocarpine, cevimeline) that stimulate salivary muscarinic receptors (M3) and increase saliva production; adverse effects include increased parasympathetic activity (eg, sweating, nausea/vomiting, wheezing) and are particularly troublesome with pilocarpine; cholinergic medications can also treat xerostomia in patients with Sjögren syndrome Removing medications (if possible) that can worsen xerostomia, such as anticholinergics and antidepressants Removing medications (if possible) that can worsen xerostomia, such as anticholinergics and antidepressants Nonpharmacologic interventions such as saline rinses, water-soluble mouth lubricants, regular dental care/surveillance, and frequent chewing (eg, sugarless gum) to mechanically stimulate salivation Nonpharmacologic interventions such as saline rinses, water-soluble mouth lubricants, regular dental care/surveillance, and frequent chewing (eg, sugarless gum) to mechanically stimulate salivation Pharmacologic therapy using cholinergic medications (eg, pilocarpine, cevimeline) that stimulate salivary muscarinic receptors (M3) and increase saliva production; adverse effects include increased parasympathetic activity (eg, sweating, nausea/vomiting, wheezing) and are particularly troublesome with pilocarpine; cholinergic medications can also treat xerostomia in patients with Sjögren syndrome Pharmacologic therapy using cholinergic medications (eg, pilocarpine, cevimeline) that stimulate salivary muscarinic receptors (M3) and increase saliva production; adverse effects include increased parasympathetic activity (eg, sweating, nausea/vomiting, wheezing) and are particularly troublesome with pilocarpine; cholinergic medications can also treat xerostomia in patients with Sjögren syndrome (Choice B) Although opioids can contribute to xerostomia, this patient likely has significant cancer-related pain and is unlikely to be able to discontinue oxycodone and long-acting morphine. (Choice C) The prolonged use of hydrogen peroxide mouthwash is not recommended due to high rates of nausea and mucous membrane irritation. (Choice D) This patient has no signs of dehydration (ie, no abnormal vital signs or orthostasis); intravenous fluids would not be indicated for short- or long-term management. (Choice E) Patients with xerostomia are at greater risk for oral candidiasis, which frequently presents with dysphagia, pain, and pseudomembranous, erythematous lesions. Treatment includes clotrimazole lozenges or nystatin suspension. This patient has no evidence of candidiasis on examination. Educational objective: Xerostomia occurs in approximately 80% of patients who receive radiotherapy for head and neck cancers. Treatment includes supportive measures (eg, saline rinses, mouth lubricants) and pharmacotherapy with parasympathomimetic agents (eg, cevimeline) to stimulate salivary flow. __________ References: Xerostomia induced by radiotherapy: an overview of the physiopathology, clinical evidence, and management of the oral damage. Page(s): PMC4325830 (http://www.ncbi.nlm.nih.gov/pubmed/4325830)

An 86-Year-Old Woman Comes to the Clinic Due to Mouth