Med/Psych Update

Psychotropic-induced dry mouth: Don’t overlook this potentially serious side effect

Current Psychiatry. 2011 December;10(12):54-58

Routine screening, education can help patients avoid substantial sequelae

References

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2. Stewart CM, Berg KM, Cha S, et al. Salivary dysfunction and quality of life in Sjögren syndrome: a critical oral-systemic connection. J Am Dent Assoc. 2008;139(3):291-299.

3. Friedman PK. Xerostomia: The invisible oral health condition. http://www.dentistryiq.com/index/display/article-display/295922/articles/woman-dentist-journal/health/xerostomia-the-invisible-oral-health-condition.html. Accessed September 6, 2011.

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6. Vanderkooy JD, Kennedy SH, Bagby RM. Antidepressant side effects in depression patients treated in a naturalistic setting: a study of bupropion moclobemide, paroxetine, sertraline, and venlafaxine. Can J Psychiatry. 2002;47(2):174-180.

7. Löffler W, Kilian R, Toumi M, et al. Schizophrenic patients’ subjective reasons for compliance and noncompliance with neuroleptic treatment. Pharmacopsychiatry. 2003;36(3):105-112.

8. Lambert M, Conus P, Eide P, et al. Impact of present and past antipsychotic side effects on attitude toward typical antipsychotic treatment and adherence. Eur Psychiatry. 2004;19(7):415-422.

9. Rettenbacher MA, Hofer A, Eder U, et al. Compliance in schizophrenia: psychopathology, side effects, and patients’ attitudes toward the illness and medication. J Clin Psychiatry. 2004;65(9):1211-1218.

10. Bulkacz J, Carranza FA. Defense mechanisms of the gingiva. In: Newman MG, Takei HH, Klokkevold PR, et al, eds. Carranza’s clinical periodontology. St. Louis, MO: Elsevier Saunders; 2011:69–70.

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12. Guggenheimer J, Moore PA. Xerostomia: etiology recognition and treatment. J Am Dent Assoc. 2003;134(1):61-69.

13. Dawes C. Physiological factors affecting salivary flow rate oral sugar clearance, and the sensation of dry mouth in man. J Dent Res. 1987;66:648-653.

14. Bartels CL. Xerostomia information for dentists. http://www.homesteadschools.com/dental/courses/Xerostomia/Course.htm. Accessed August 15, 2011.

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17. Quirynen M, Van den Veide S, Vanderkerckhove B, et al. Oral malodor. In: Newman MG, Takei HH, Klokkevold PR, et al, eds. Carranza’s clinical periodontology. St. Louis, MO: Elsevier Saunders; 2011:333.

18. Papas A. Dry mouth from drugs: more than just an annoying side effect. Tufts University Heath and Nutrition Letter. 2000;3.-

19. American Academy of Periodontology. Gum disease information from the American Academy of Periodontology http://perio.org. Accessed August 12, 2011.

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21. Lee HJ, Garcia RI, Janket SJ, et al. The association between cumulative periodontal disease and stroke history in older adults. J Periodontol. 2006;77(10):1744-1754.

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Xerostomia, commonly known as “dry mouth,” is a reported side effect of >1,800 drugs from >80 classes.¹ This condition often goes unrecognized and untreated, but it can significantly affect patients’ quality of life and cause oral and medical health problems.^2,3 Although psychotropic medications are not the only offenders, they comprise a large portion of the agents that can cause dry mouth. Antidepressants, anticonvulsants, anxiolytics, antipsychotics, anticholinergics, and alpha agonists can cause xerostomia.⁴ The risk of salivary hypofunction increases with polypharmacy and may be especially likely when ≥3 drugs are taken per day.⁵

Among all reported side effects of antidepressants and antipsychotics, dry mouth often is the most prevalent complaint. For example, in a study of 5 antidepressants 35% to 46% of patients reported dry mouth.⁶ Rates are similar in users of various antipsychotics. Patients with severe, persistent mental illness often cite side effects as the primary reason for psychotropic noncompliance.^7-9

Few psychiatrists routinely screen patients for xerostomia, and if a patient reports this side effect, they may be unlikely to address it or understand its implications because of more pressing concerns such as psychosis or risk of suicide. Historically, education in general medical training about the effects of oral health on a patient’s overall health has been limited. It is crucial for psychiatrists to be aware of potential problems related to dry mouth and the impact it can have on their patients. In this article, we:

describe how dry mouth can impact a patient’s oral, medical, and psychiatric health
provide psychiatrists with an understanding of pathology related to xerostomia
explain how psychiatrists can screen for xerostomia
discuss the benefits patients may receive when psychiatrists collaborate with dental clinicians to manage this condition.

Implications of xerostomia

Saliva provides a protective function. It is an antimicrobial, buffering, and lubricating agent that aids cleansing and removal of food debris within the mouth. It also helps maintain oral mucosa and remineralizing of tooth structure.¹⁰

Clinical Point

Psychotropics can affect the amount of saliva secreted and may alter the composition of saliva

Psychotropics can affect the amount of saliva secreted and may alter the composition of saliva via their receptor affects on the dual sympathetic and parasympathetic innervations of the salivary glands.¹¹ When the protective environment produced by saliva is altered, patients may start to develop oral problems before experiencing dryness. A 50% reduction in saliva flow may occur before they become aware of the problem.^12,13

Patients may not taste food properly, experience cracked lips, or have trouble eating, oral pain, or dentures that no longer fit well.¹⁴ Additionally, oral diseases such as dental decay and periodontal disease (Photos 1 and 2), inflamed soft tissue, and candidiasis (Photo 3) also may occur.^10,15 Patients may begin to notice dry mouth when they wake at night, which could disrupt sleep. Patients with xerostomia can accumulate excessive amounts of plaque on their teeth and the dorsum of the tongue. The increased bacterial count and release of volatile sulfide gases that occur with dry mouth may explain some cases of halitosis.^16,17 Patients also may have difficulty swallowing or speaking and be unaware of the oral health destruction occurring as a result of reduced saliva. Some experts report oral bacteria levels can skyrocket as much as 10-fold in people who take medications that cause dry mouth.¹⁸

Clinical Point

Untreated xerostomia can result in major dental problems and chronic systemic inflammatory conditions

Infections of the mouth can create havoc elsewhere in the body. The evidence base that establishes an association between periodontal disease and other chronic inflammatory conditions such as diabetes, cardiovascular disease, cancer, and rheumatoid arthritis is steadily growing.^19-22 Periodontal disease also is a risk factor for preeclampsia and other illnesses that can negatively affect neonatal health.^23,24

Failure to recognize xerostomia caused by psychotropic medications may lead to an increase in cavities, periodontal disease, and chronic systemic inflammatory conditions that can shorten a patient’s life span. Recognizing and treating causes of xerostomia is vital because doing so may halt this chain of events.

Photo 1
This patient complained of dry mouth and exhibits decay (a) and evidence of periodontal disease. Plaque and calculus is present (b), along with gingival recession from the loss of attachment and bone (c). This patient was taking venlafaxine, zolpidem, and alprazolam

Photo 2
Dental cavities were restored with tooth-colored restorations (arrows) on this patient, who has xerostomia. Every effort must be made to manage this patient’s dry mouth or the restorations may fail due to recurrent decay

Photo 3
This partial denture wearer, who complained of dry mouth, has evidence of palatal irritation and sores as a result of xerostomia and use of a partial denture. This patient was taking bupropion, esomeprazole, and tolterodine