Comprehensive Assessment of Dry Mouth: A Nursing Perspective

This report provides a comprehensive overview of the assessment and management of a 55-year-old woman presenting with dry mouth, focusing on salivary glands, temporomandibular joint (TMJ) disorders, and associated pain. It begins with an introduction to orofacial disorders, particularly hyposalivation and xerostomia, emphasizing the importance of systematic evaluation. The report details the roles of saliva, the prevalence of dry mouth, and its various etiologies, including systemic conditions like Sjögren's syndrome and local factors such as medications and lifestyle choices. The assessment section outlines a patient-centered approach, including the use of questionnaires, oral examinations, and saliva flow rate tests. The report also covers the diagnosis of salivary gland disorders, the signs and symptoms of dry mouth, and the differentiation between Sjögren's syndrome, xerostomia, and TMJ disorders. Finally, it addresses management strategies, including hydration, medication adjustments, and the use of saliva substitutes, to reduce the impact of xerostomia and improve the patient's quality of life. The report incorporates multiple references to support the information and guide the reader.

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NURSING
Name
Institution
Tutor
Date

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Salivary, TMJ, and pain (2nd Years and Dental Specialties)
A 55-year-old woman presents to your clinic complaining of a dry mouth. She has no relevant
medical history other than taking Viscotears. Describe your assessment and management of this
patient
Introduction
Orofacial disorders and dysfunctions affect the well-being and confidentiality of a human being,
therefore it requires special attention from a qualified dentist to intervene in the situation. More
particularly in the case (a 55yr old woman complaining of dry mouth who is currently using
Viscotears), it is essential to do systematic evaluation and assessment in salivary glands, TMJ
and any other pain to provide factual management and treatment techniques.
Salivary glands dysfunctions and abnormalities are characterized with mouth dryness, swollen
glands, and development of tumors in glands. (Michael Friedman, 2018). These finally affects
the rate of production of saliva in the mouth hence Hyposalivation and Xerostomia. Seemingly,
hyposalivation and xerostomia are two different entities although commonly used as one.
Hyposalivation is the diminished production of saliva which can be determined using sialometry
kit while Xerostomia is the objective sign of dryness in mouth (Ying Joanna, N. D., et al. 2015).
According to Michael D. Turner’s research, it is objective that the normal, unstimulated of
salivary secretory rate vary a range of 800 to 1500 ml per day or 0.3 to 0.4 ml per minute. Below
this range, it is clearly noted that the patient is affected with mouth dryness i.e. hyposalivation or
xerostomia.
Saliva is an essential element in the mouth and plays a great role as a lubricating agent, softening
food before swallowing, easing speech and cleaning the remains in the mouth. Besides those

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vital roles, it inhabits essential components like mucin which protect teeth against
demineralization and any other damage. It is enzymatic to assist in the digestion of starchy foods.
(Turner, M.D. 2016).
Recently, it has been depicted that the hyposalivation and xerostomia are affecting women and
men in a ratio of 9:1 and more evident in women of 50 years old (Xavier and Lindsey, 2018). It
has also been noted that the population suffering from the infections ranges from 5% to 47%
( Millsop et al., 2017).
It has been frequently noted that the patients diagnosed with xerostomia are manifested with
difficulty in speaking, chewing and swallowing, mouth inflammations, candidiasis, peeled and
cracked lips, glossitis, halitosis, dry buccal mucosa, and dental caries despite good hygiene
(Millsop et al., 2017).
The etiologic of xerostomia can be further subdivided into systematic infections and local
factors. Where systematic infections that can intrigue Xerostomia are; autoimmune, endocrine,
granulomatous diseases and infectious. On the other hand, local factors that lead to xerostomia
include medications, lifestyle, and radiation therapy on the neck (Millsop et al., 2017).
Under systemic conditions, Sjӧgren's syndrome (ss) is autoimmune infection associated with
hyposalivation manifestations like dry mouth. Another closely related disease with Sjӧgren's
syndrome in autoimmune include; primary biliary cirrhosis, scleroderma, systemic lupus and
finally rheumatoid arthritis. These affect salivary gland tissues hence xerostomia symptomatic
(Millsop et al., 2017). In autoimmune thyroid diseases, usual salivary glands are targeted by the
immune system. In either way, serum antibodies rise against thyroid antigens (Millsop et al.,
2017).

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In local factors, it has proven that over 400 medications also lead to hyposalivation and
xerostomia. These include antidepressant medications, antiparkinsonian medications and atypical
antidepressant medications which affect the functioning of salivary glands. Also, another
lifestyle may be another inducer for the disease (Aby et al., 2013). The lifestyle factors include;
addictive use of cigar and alcohol, use of beverages and heavy snoring which lead to mouth
dryness. Neck and head radiations therapy lead to the destruction of stem cells and acinar hence
hyposalivation and xerostomia (Millsop et al., 2017).
Apparently, patients with Sjӧgren syndrome (ss) autoimmune diseases always complain of dry
mouth, eye dryness, and pain. They should always have to be subjected to queries about
manifestations of primary Sjӧgren syndrome and autoimmune infections within their family
(Mariette, M.D. et al., 2018).
Temporomandibular disorders (TMD) are a masticatory muscle infection where the patients
normally complain of pain on orofacial joints during open and closing of the mouth. Also, some
other minor symptoms include pain on ear, neck, headache, fatigue and some dizziness. Usually,
the patients are too unproductive during work and affect the quality of life.
In our case, then a 55-year-old woman who has been subjected to the use of viscotears and with
no other medical histology, definitely shows that she is infected with Sjӧgren syndrome under
autoimmune diseases. Therefore, the paramedic concerned with evaluation should properly
subject her to queries which can enable him/her to prescribe treatment and any other required
management. Viscotears are those medications prescribed to patients who are experiencing
complaining of eye dryness. Therefore, for the provision of quality medication, the paramedic
needs to carry out tests and assess the above-discussed infections to provide the patient with

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appropriate medications and necessary instructions for management of the disease (Eliasson and
Carlén, 2014). Orofacial ideal management techniques for the patient will enable the patient to
recover the quality life hence productivity.
Salivary glands
As stated, saliva is usually produced in the salivary glands and it is empirically categorized into
two i.e. serous and mucinous which plays a greater role in the mouth. Mucinous and serious
come up together to form one component known as saliva. Salivary glands are majorly broken
into parotid, submandibular and sublingual. Parotid usually secretes serous only, as
submandibular secretes both serous and mucous elements of saliva while sublingual and other
minor salivary glands secrete mucinous only (Turner, M.D. 2016). When the glands are affected
the human comfort, quality of life, oral hygiene and productivity are affected due to its anatomic
position in the body. Hence, the intervention of the dental practitioner (Leal et al., 2016).
Assessment
Assessment of the patients with orofacial disorders like hyposalivation or xerostomia generally
requires the paramedic or dental practitioner to base it as patient-centered. The practitioner
should prepare the number of queries to the patient. The global item approach is the most
essential method which any practicing clinician or clinician can employ to understand
xerostomia symptoms (Kumar and Sathasivasubramanian, 2017). This approach enables the
individual to integrate the perception, behavior, feeling and the experience of the entity being

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measured before any judgment. Example of the questions; how often do you experience mouth
dryness? when did it start? Is there any pain when you open and close the mouth? have you taken
any medications? These will enable the medic to also understand the histology of the patient
he/she handling. The patient can also be asked to explain the symptoms which will reveal to the
clinician the best method of measuring the mouth dryness. He/ she will be able to make a clear
judgment about the disease (Adenocarcinoma of the Salivary Gland Metastatic to the Pituitary
Gland: Case Report, 2015). He /she will be able to scale the infections either worse, bad or good
condition before giving out management criterion of the patient (Thomson, 2015).
The specialist will involve the patient with thorough oral medical examination to determine the
real signs of hyposalivation or xerostomia like stick dental mirror, foamy saliva, glassy mucosa,
smoothed gingiva, loss of papillae, fissured or lobulated tongue, buccal mucosa and
accumulation of minimal saliva in the lower part (Millsop et al., 2017). This will enable the
specialist to understand the infections better which if affect the fifty-five-year-old woman.
For the medic to understand better about the cause of these diseases, he/she should investigate
the histology of the patient. The dentist should get informed from the patient if at any given she
has been exposed to any radiations killing the salivary glands. When the salivary glands are
exposed to any radiations during any operation either accidentally or for medical purpose on the
neck or head; they may end up dying (Turner M.D.,2016).
Then the clinician/the dentist should test the flow rate of the saliva using one of the appropriate
methods either drain, spit, suction and swab methods (Thomson,2015). The saliva will be
collected in the lower part of the mouth after cleansing and rinsing the mouth. The fresh volume
collected from the mouth will then be calculated to determine the rate of flow of saliva and then

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compared to the stipulated rate. The clinician will comment on the rate of flow of saliva if okay
or affected. From the standard rate of 0.3 to 0.4 ml per minute, the clinician can comment
worse/bad if it is below 0.3 ml per ml and give the patient any effective management practice
(Yoruk et al., 2017). The appropriate tool kit for this is a Sialometry.
To diagnose the salivary gland, the specialist can opt to do salivary gland imaging which
includes sialography, computed tomography scan, magnetic resonance salivary gland scan and
scintigraphy with technetium -99m. These can be done if the systemic disorder like Sjӧgren
syndrome is doubted and for that particular case anti-La bodies and anti-RO can be tested
(Millsop et al., 2017). This will give a clear image to the dentist about the salivary gland. The
specialist will be able to identify the problem in the patient and make the judgment for
management and necessary medication.
Under any circumstance, if Sjӧgren syndrome is doubted the clinician will advance to a minor
salivary gland biopsy. The biopsy will be collected from the lower lip and the area will show that
at least 50 lymphocytes/4mm2 (Millsop et al., 2017) Therefore, it is better to understand Sjӧgren
syndrome diagnosis in order to handle dry mouth manifestations.
Understanding the signs and symptoms of dry mouth
The specialist in orofacial disorder and dysfunctions must understand the following basic signs
and symptoms in order to assist the fifty-five-year-old woman to manage the malady effectively.
Signs
Cracks in the corner of the mouth
Swelling salivary glands

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Mucositis
Dry cracked and peeling lips
Dental erosion
Oral candida
Oral ulcers
Symptoms
Mouth inflammation
Pain in salivary glands
Sensitive to spicy foods
Difficulty in chewing and swallowing
Thirsty always
Source: (Singapore dental journal,2015)
To be able to diagnosis for the Sjӧgren syndrome, hyposalivation and xerostomia the specialist
should understand the critical difference between them and temporomandibular disorders
(TMD). Therefore, Temporomandibular disorders (TMD) can be defined as a multifactorial
disease which is caused by parafunction, trauma, muscle hyperfictional, the influence of
hormones and other articulate changes in the body (Liu and Steinkeler 2013). In general, the
disease involves pain in the orofacial joints i.e. the upper and the lower joint. To examine TMJ
infections, the specialist should involve the patient in order to understand history. Palpation

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should be applied bilaterally on upper, lower and right of the jaw of the muscles to examine
temporomandibular disorders (TMD) (Taylor, Serpell and Thomson, 2015).
Radiography studies can be used to evaluate infections. They include peripheral radiograph,
panoramic radiographs, and cone beam computed tomography scans can be used to generate the
imagery. Also, the MRI modality choice can be used to determine the method of treatment (Liu
and Steinkeler 2013). The radiograph can help the specialist to make judgments about
temporomandibular disorders and also enable him or her to prescribe the effective management
way.
The common signs in temporomandibular disorders (TMD) include; dizziness, headaches,
earache, inflammations in the joints and locked mouth. The symptoms of temporomandibular
disorders (TMD) temporal headaches and muscular contracture (Tyagi and Dey, 2015).
Management
In recent year there has been aiming to reduce patients affected with xerostomia. The researchers
have come up with suggestive factual to reduce the patients like hydration, use sugar-free
chewing gums, avoid irritating dentifrices hard or crunchy food and avoid humidity during night
hours. Also, the probable medication is available to reduce the number of patients affected with
xerostomia (Villa Et al., 2015).
If patient using is using any xenogeneic drug which might be contributing mouth dryness
(xerostomia), she should be advised by the physician to leave some or make a change for her
(Thomson,2015). Some xenogeneic diseases hence causing xerostomia and hyposalivation.

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Patients should further seek advice with the physician. If possible the patient can leave the drugs
to better the situation.
Alternatively, the patient can use mechanical stimulators to increase the flow of saliva for the
glands. The patient should use chewing gum as stimulators to increase the rate of flow of saliva
(milliliter per minute). Researchers have noticed that chewing gums causes the parotid capsule to
stretch and compress the parotid gland (Liu et al., 2018). Pilocarpine and cevimeline have been
approved by US food administration, that they increase secretion of saliva from the glands.
These two foods affect muscarinic receptors in the body hence secretion of saliva. It has been
revealed also that they diminish the cholinergic effect in the body (Liu et al., 2018).
The patient should be advised to use sodium fluoride instead of using calcium fluoride which
demineralization hence affecting oral hygiene (Lombaert, Knox and Hoffman, 2014). Under this
condition, the enamel is demineralized to avoid attrition and erosion of the enamel.
The patients should be advised to use intravenous antifungal agents, oral and topical agents.
These agents include voriconazole, anidulafungin, casptufungulin, micafungin, posaconazole,
clotimazole and flucyutosine capsule among other.
The patients can be advised to use agents to prevent desiccation and coat mucosa hence reducing
inflammation (Lv et al., 2013).
Patients who have been exposed to radiotherapy are advised to use amifostine agent. Amifostine
helps them to be relieved from the radiography which may affect them (Ozyol and Ozyol, 2016).

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The patient should be asked to stop smoking, drinking alcohol and any other alcoholic beverages
which transpires dehydration in the mouth. Also if the patient is snoring heavily, he/she should
be advised to stop (Millsop et al., 2017). Such life style activities affect the patient negatively
hence patient should be warned against them.
Also the patients who are willing to stop medication for hyposalivation and xerostomia shall
inform the medic first. The patients should seek for the check up from the dentist to allow them
to withdraw the use of the prescribe (Tarjan, 2013).
Generally, the patients and even those who are not suffering from the disease are advised to keep
the oral hygienic rule. This will reduce the chases of infection and will also protect the enamel. It
has been known that everyone should brush teeth after every meal and this should be applied by
everyone to reduce the patients affected with hyposalivation and xerostomia.
Those patients are diagnosed with TMJ should be subjected to physical therapy to relieve
musculoskeletal pain, reduce inflammation and reduce oral motor function.
If the patient needs total TMJ replacements, it should be clearly and efficiently done to avoid any
damage to the skull again. Sometimes it is quite difficult to transplant the organ into the living
creation. Therefore, necessary precautions should be taken before any transplant is done if it is
necessary.
Conclusion
In conclusion, any orofacial disorder or dysfunction should be addressed in time to avoid any
further complication. A simple assumed problem like temporomandibular disorders may lead to
total displacement if not addressed in time or well addressed.

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Also the practitioner should be keen enough on the history of the patient before subjecting the
patient on any management or treatment criterion to avoid complication.