Ralph H. Saunders, DDS, MS; Stanley L. Handelman, DMD
Effects of hyposalivatory medications on saliva flow rates and dental caries in adults aged 65 and older Institutionalized adults aged 65 or older often receive medications that have been associated with decreased saliva flow. Flow rates depressed by hyposallvatory medications are thought to increase susceptibility to dental caries. In this study, a crosssectional comparison was made of stimulated whole saliva rates and coronal and root caries prevalence in a group of older adults, in a long-term care facility, taking hyposalivatory medications vs. a control group. No significant differences were found between the two groups in masticatory or gustatory stimulated flow rates or in mean decayed coronal or root surfaces.
dults aged 65 and older use more hyposalivatory medications than do those in other age groups.’ A potential consequence of reduced saliva flow as a result is increased susceptibility to dental caries. Increased incidence of caries in animals and humans has been welldocumented subsequent to massive radiation to the head and neck and following surgical de~alivation.~.~ Severe decay has also been reported in case studies describing large, multiple doses of psychoactive medications with hyposalivatory proper tie^.^.^ Older adults in long-term care facilities receive many psychoactive medications as well as diuretics, GI/ urinary tract agents, antihistamines, antihypertensives, and other medications which may have hyposalivatory properties. However, few investigations have studied the extent to which the saliva flow rate is reduced in older adults taking medications and living in nursing home^.^,^ Furthermore, the effects of salivary flow reduction on dental caries prevalance and incidence have not been adequately explored. Thus, this preliminary investigation compared saliva flow rates and the prevalence of coronal and root caries in a group of older adults using hyposalivatory medications with a similar group not using these medications.
Patients and methods The subjects for the study were a dentate sample of residents of a nursing home in Rochester, NY. Study subjects were 65 years of age or older, had at least six teeth (excluding third molars), and were mentally and physically capable of participating in
116 Special Care in Dentistry, Vol12 No 3 1992
the examination sessions. Subjects with five or fewer teeth were not included, because it has been reported that saliva flow may be diminished when few or no teeth are present.lo,ll The nursing home had 219 residents. Of these, 157 volunteered to be screened for the study. Of those screened, 88 (57%)had at least six teeth and were eligible study subjects. Of the 88 eligible subjects, 57 consented to participate and became the study sample. Two samples of stimulated whole saliva (one masticatory and one gustatory) were obtained from each subject. Various stimuli for obtaining saliva were used, because the type of stimulus which produces the most representative flow has not been conclusively established in the literature. Initially, subjects were asked to place a sterilized rubber band in their mouths and to chew on the band at a steady but comfortable rate. Next, they were instructed to expectorate gently, into a plastic cup, any saliva that had accumulated in their mouths any tirpe they felt the urge to swallow, but no less often than once every 60 seconds for a period of 5 minutes. At this session, the names and dosages of all medications currently being used were recorded. Medications being used by study subjects were classified as hyposalivatory or not hyposalivatory, according to a modified method of classification established by ~ this method, Handelman et ~ 1 . ’ For information regarding all medications used by the study population was reviewed in the Physician’s Desk Referen~e’~, the Physician’s Desk
Reference for Nonprescription DrugsI4,the Physician's Desk Reference for Ophthalrnol~gy~~, AMA Drug Evaluations'b,and The Pharmacological Basis for therapeutic^'^. If xerostomia or reduction in saliva flow was a recognized effect or side-effect of a medication used by the study population, or if the medication belonged to a group recognized to have a hyposalivatory potential, the medication was classified as hyposalivatory. Recent studies*Ja,lsof older adults have quantified the use of various medications on saliva flow rates in older adults and have implicated diuretics as having significant hyposalivatory potential. Thus, the Handelman'* method of classification was modified in the current study to include diuretics. During a second-session collection period, a gustatory-stimulated saliva sample was obtained in accordance with the methods of Navazesh and By means of a sterile Chri~tensen.'~ dropper, four drops of 2% citric acid were placed on the anterior dorsal surface of the tongue at 60-second intervals. Again, subjects were instructed to expectorate gently into a plastic cup whenever they had the urge to swallow but not less often than every 60 seconds for a period of five min. Saliva flow rates were then calculated as mL/min. Study subjects were restricted from eating, drinking, and smoking for at least one h prior to saliva collection. All saliva samples were obtained between 2:OO p.m. and 4:OO p.m., the acrophase of the usual diurnal variation in flow rate. The acrophase was selected because there was concern that flow rates might be extremely low for persons taking medications at other times. Immediately after the gustatorystimulated saliva sample was obtained, the numbers of decayed and filled coronal and root surfaces were recorded. Coronal caries was described according to the criteria of Radike20and root caries according to ' two the criteria of Banting et ~ 1 . ~The examiners who recorded the study data were rated against each other (90%agreement) and against an experienced examiner (90%agree-
Table 1. Ten most common medical diagnoses in study populatlon.
Table 2. Dlstrlbutlonof hyposalivatory medications used by study populatlon.
Diagnosis No. of Subjects Hearing loss 24 Degen. joint disease 24 Arterioscleroticheart disease 17 Anxiety 15 Constipation 13 Cataracts 13 Congestive heart failure 12 Angina 11 Glaucoma 11
Diuretics Furosemide (Lasix) Hydrochlorothiazide (Esidrix) Acetazolamide (Diamox) Chlorthalidone (Hygroton) Triamterene, Hydrochlorothiazide (Dyazide) Methazolamide (Neptazane) Spironolactone(Aldactone) Sedative/ hypnotics Diazepam (Valium) Flurazepam (Dalmane) Temazepam (Restoril) Chlordiazepoxide(Librium) Triazolam (Halcion) Lorazepam (Ativan) Oxazepam (Serax) GI/urinary tract Diphenoxalate,atropine (Lomotil) Atropine, scopalamine, hyoscyamine, phenobarbital (Donnatal) Propantheline (Pro-Banthine) Metoclopromide(Reglan) Antihistamines Chlorpheniramine (Chlor-Trimeton) Meclizine (Antivert) Diphenhydramine (Benadryl) Agents for pain control Propoxyphene (Darvon) Codeine (Empirin,Codeine) Ibuprofen (Motrin) Antipsychotics/ antidepressants Trifluoperazine (Vesprin) Imipramine (Tofranil) Doxepin (Adapin) Antihypertensives Prazosin (Minipress) Chlorothiazide,Reserpine (Diupress) Captopril (Capoten) Anti-Parkinson's agents Procyclidine (Kemadrin) Carbidopa/levodopa (Sinemet) Cardiovascular agents Nadolol (Corgard)
ment) so that consistency for both coronal and root decay evaluations would be ensured.
Results The age range of study subjects was 66-93 (mean, 83.4 k 5.4 SD) years. The ratio of male to female subjects in the study population was approximately 1:6, and the mean number of teeth was 17.9 f 6.8 (SD). The numbers of teeth for males and females were 15.8 f 7.3 (SD) and 18.4 f 6.7 (SD),respectively. For the study population, 67% had at least one coronal surface with untreated caries. The mean number of decayed coronal surfaces was 2.0 f 2.5 (SD). The population had a mean of 2.7 f 3.6 (SD) decayed root surfaces. The percentage of the population affected with root decay was 70.2. The Root Caries expressed as a percentage of the total number of surfaces was 25.0 f 20.4 (SD). The mean masticatory stimulated flow rate was 0.42 f 0.36 (SD) mL/ min. The gustatory flow rate was 1.01 f 0.55 (SD) mL/min. The 10 medical diagnoses (International Classification of DiseasesClinical Modification, 1980) found most commonly in this population are listed in Table 1. None of the study subjects had Sjogren's syndrome, was receiving head and neck radiation or chemotherapy, suffered from salivary gland pathological conditions, or had any other untreated disorder identified as affecting salivary flow rate. The percentage of each hypo-
%*
18.3 4.2 4.2 1.4 1.4 1.4 1.4 %
14.1 2.8 2.8 2.8 2.8 1.4 1.4 %
5.6 2.8 1.4 1.4 %
2.8 2.8 2.8 %
4.2 1.4 1.4 %
1.4 1.4 1.4 %
1.4 1.4 1.4 %
1.4 1.4 1.4
* Total does not exactly equal 100%due to rounding.
Special Cam in Dentistry, Vol12 No 3 1992 117
Table 3. Masticatory and gustatory saliva flow rates by hyposalivatory medication use.
Masticatory
Gustatory
Flow Rate (mL/min) . .
Flow Rate (mL/min) . .
Medication Use
No. of Subjects
Subjects
None
12
21
0.61 f 0.45‘
1.12 f 0.49
Somet
45
79
0.38 f 0.32
0.98 f 0.57
NS’
NS
(Yo)
Mean f SD. Difference by medication group compared by Student’s t test. * NS = Not significant. *
Table 4. Decayed and filled coronal sutfaces by hyposalivatory medication use.
Hyposalivatory Medication Use None Some* (n = 12) (n = 45) Decayed surfaces Mean surfaces/subject
1.8 2.4+
+
2.1 f 2 . 6
NS’
Percentage of surfaces
2.2 f 2.8
3.6k5.6
NS
Mean surfaces/subject
35.5 f 19.1
35.3+ 24.9
NS
Percent of surfaces
38.2 f 16.3
43.7f 24.6 NS
Filled surfaces
*
Differences by medication group compared by Student’s t test. Mean SD. * NS = Not significant. +
*
salivatory medication is noted as a percent of the total hyposalivatory medications (Table 2). The mean duration of use of hyposalivatory medications by study subjects was 11.9 9.9 (SD) months (range, 1-50 months). Because pharmacological dosages for study subjects were not large, it is likely that the duration of medication use had more influence than dose levels on saliva flow. Table 3 presents the masticatory and gustatory saliva flow rates by hyposalivatory medication used. Seventy-ninepercent of the study subjects were taking at least one hyposalivatory medication. Those taking hyposalivatory medications had relatively low masticatory flow rates compared with those not taking them; however, the differences were not statistically significant. For gustatory flow rates, the difference between groups was less but was in the same direction (i.e., the group taking the medications had lower flow rates).
+
Decayed and filled coronal surfaces by medication used are presented in Table 4. Both mean decayed surfaces and percentage of surfaces decayed were slightly greater for those using hyposalivatory medications than for those not using them; however, these differences were not statistically significant. Filled surfaces were almost identical between the two groups. Decayed and filled root surfaces and the Root Caries Index were greater for subjects using hyposalivatory medications (Table 5). These differences were greater than those for coronal surfaces but were not statistically significant. Spearman correlation coefficients for the relationship between decayed and filled coronal surfaces and saliva flow rates are presented in Table 6. These coefficients provide no evidence of a relationship between these variables for study subjects. However, low inverse correlations were observed when the relationship between decayed and filled root
118 Special Care in Dentistry, Vol12 No 3 1992
surfaces and flow rates was analyzed (Table 7), suggesting that decreased flow rates may be accompanied by increasing levels of root decay.. The relationships with filled root surfaces and the Root Caries Index to the flow rates were statistically significant.
Discussion Thirty-one percent of the total population screened (n = 157) was edentulous. By the criteria of prevalence of edentulousness, the total population was dentally healthy; most studies of older adults in long-term care facilities have reported rates of edentulousness ranging from 60 to 90%.2D-2R The study sample was relatively small, as is frequently the case with investigations of special patient population^.^^ Possible trends toward decreased saliva flow and increased caries in subjects taking medications were observed, although differences were not statistically significant. There are significant logistical and economic obstacles to the completion of epidemiological studies in a single population of long-term care facility residents. A larger sample of institutions would be necessary for the results to be generalizable. Repeat studies or multi-center investigations are recommended. The distribution of potentially significant medical diagnoses between the two groups was similar with the exception of diabetes mellitus. All seven of the persons with diabetes were taking hyposalivatory medications. Because the impact of diabetes on saliva flow rates is not wellestablished, mean flow rates were calculated for this subgroup. The mean masticatory flow rate for subjects with diabetes, all of whom were receiving treatment if necessary, was 0.55 mL/min; the mean gustatory flow rate was 1.23 mL/min. These values were slightly higher than the means for the entire population, suggesting that individuals with diabetes in the current study were not at increased risk for low saliva flow. The mean number of medications used by study subjects was 6.5. This number is relatively high compared
with two other studies of long-term care facility popu1ations.”,l2These higher levels may be attributed to vitamins, topical preparations, and pro re nata medications included in the current study. The proportion of subjects using hyposalivatory medications (79%)was higher than that of an earlier long-term care facility survey in which diuretics were not included.12 It is similar to a recent investigatioxP that did include these medications. Definitive classification of medications by their potential to affect the perception of mouth dryness and actual decreased saliva output is difficult. Limited research in this area has produced conflicting results. For example, recent studies of long-term care facility residents8~1U,’s have reported reduced flow rates when diuretics are taken. However, five young males taking the diuretic furosemide did not have decreased saliva flow but did have an increased perception of mouth dryne~s.~’ It should be noted that, while, for statistical analysis, subjects in this study were dichotomized into those taking and not taking hyposalivatory medications, other divisions were possible that might have affected the results. However, other groupings were evaluated, including a division of subjects into those taking 0, 1, and 2 or more hyposalivatory medications, and none of these demonstrated significant differences according to gustatory or masticatory flow rates, incidence of coronal or root caries, or total number of medications used. Pharmacological effects on both stimulated and resting saliva flow rates have been investigated. Stimulated salivary flow rates were selected for this study partially because of the difficulty of collecting measurable amounts of unstimulated saliva in frail older persons. Persson et a1.18, in a study of a similar population, attempted to collect both stimulated and unstimulated samples, but they were unsuccessful in obtaining viable amounts of unstimulated saliva. Both stimulated and unstimulated flows have been found to be depressed by the use of certain medications, although the effects are probably not completely ~omparable.’,~~ A study of
Table 5. Decayed and filled root surfaces by hyposalivatory medication use.
-~ _
_
~
_
Hyposalivatory Medication Use None Some* (n = 12) = 45) (n ~ _ _
_
Decayed surfaces Mean surfaces/subject
1.8 f 2.2’
2.9f 3.8
NS*
Percent of surfaces
4.0 f 3.5
8.9k 12.6
NS
* 7.7
NS
Filled surfaces Mean surfaces/subject
8.1
4.5 f 3.6
Percent of surfaces
12.05 11.2
19.4f 19.6 NS
15.8f 12.0
27.5f21.6
Root Caries Index (RCI) (Surfaces percent)
NS
*
Differences by medication group compared by Student’s t test. Mean f SD. * NS = Not significant. +
Table 6. Correlations between decayed and filled coronal surfaces and masticatory and gustatory saliva flow rates.
Masticatory Flow Rate
Gustatory Flow Rate
p value _ ~
r*
p~ value
Decayed
-0.07
0.60
0.04
0.79
Filled
0.01
0.96
-0.21
0.10
~~
~
~
_
_
r
_
_
_
_
* Spearman Correlation Coefficient,
Table 7. Correlations between decayed and filled root surfaces and Root Caries Index and masticatory and gustatory saliva flow rates.
Masticatory Flow Rate
Gustatory Flow Rate
r‘
p value
r
p value
Decayed
-0.18
0.18
-0.17
0.20
Filled
-0.29
0.03
-0.29
0.02
Root Caries Index (RCI)
-0.32
0.02
-0.26
0.05
* Spearman Correlation Coefficient.
healthy outpatients found that stimulation reduced, but did not eliminate, the saliva-depressive effects of medication.32If this is correct, then the differences seen between subjects taking and those not taking hyposalivatory medications in the current study may have been greater if resting flow could have been measured. In one study”’ of 70-yearold persons, stimulated flow rates varied less than resting flow in response to the use of medications. Thus, the stimulated rates were thought more reliably to reflect the effects of medications. Measures of both stimulated and unstimulated flow rates of whole saliva and indi-
vidual glands may be needed to describe salivary gland function ~ompletely.’~ In 1977, Makila” investigated masticatory stimulated flow in a dentate population of a long-term care facility. Flow rates were one-third to one-half higher than those of the current study, possibly because of the greater proportion of males in that population. It is known that saliva flow rates for males are higher than those for f e m a l e ~ . ~ J ” ”In , ~the ~-~~ current study population, the percentages of males in the medication group (13%)and the non-medication group (16%)were similar, and so it is unlikely that gender differences
Smcial Care in Dentistry, Vol12 No 3 1992 119
~
disproportionately influenced the flow rates of these two groups. Whole saliva flow stimulated with citric acid in a population of older adults not living in long-term care facilities%had flow rates of 1.48 mL/ min for males and 1.28 mL/min for females. The higher rates found in that study33may be attributed to the subjects involved, who were healthier and used no medications. In our study, flow rates for both stimuli were less for subjects using hyposalivatory medications than for those not using them; however, the differences were not statistically significant. Diminished saliva flow rates have been reported in other studies8,10J8 of older adults receiving hyposalivatory medications.*JoJ8 Subjects using hyposalivatory medications had slightly higher (although not statistically significant) percentages of decayed and filled coronal tooth surfaces than those not using these medications. Three case report^^-^ in the literature have described the appearance of severe caries when high doses of single or multiple psychotropic medications have been used for therapeutic periods of up to 3 years. Persson et d . l S found no significant differences in DMFS for long-term care facility residents taking and not taking hyposalivatory medications. The results of the present study appeared to be consistent with those of an in~estigation~~ of both residents of long-term care fcilities and community-based persons in which those using medications with a definite hyposalivatory effect had more root caries than did those using none.
Summary and conclusions This article reports on a preliminary study of the relationships among hyposalivatory medication use, saliva flow rates, and dental caries in a longterm care facility population, aged 6593. Seventy-nine percent of subjects were taking hyposalivatory medications, and these patients had a higher Root Caries Index than did those subjects not taking hyposalivatory medications. Although subjects taking these medications had lower
absolute saliva flow rates and higher levels of coronal and root caries than did those not using hyposalivatory medications, these differences were not statistically significant. Because of the small sample population in this study, larger crosssectional and longitudinal investigations are needed for clarification of the extent to ,whichsignificant differences may be present. So that sufficient numbers of subjects can be enrolled, these studies should be multi-center in design. This research was supported by Grant No. P50DE07003 from the National Institute of Dental Research. Dr. Saunders is Clinical Associate and Coordinator of Geriatric Dentistry, Eastman Dental Center, and Associate Professor of Clinical Dentistry, University of Rochester, NY. Dr. Handelman is Chairman of the Department of General Dentistry, also at Eastman. Address reprint requests to Dr. Saunders, Eastman Dental Center, 625 Elmwood Avenue, Rochester, NY 14620. 1. Sreebny L, Valdini A, Yu A. Xerostomia. Part 11: Relationship to nonoral symptoms, medications, and diseases. Oral Surg Oral Med Oral Pathol68:419-27,1989. 2. Bowen W. The induction of rampant caries in monkeys (Macaca iris). Caries Res 3227-37,1969. 3. Bowen W, Pearson S, Young D. The effect of desalivation on coronal and root surface caries in rats. J Dent Res 6721-3,1988. 4. Edgar W, Bowen W, Cole M. Development of rampant dental caries and composition of plaque fluid and saliva in irradiated primates. Oral Path 10284-95, 1981. 5. Stevens J, Wilkinson E. Medications, dry mouth and dental disease. Psychomatics 12310-12,1971. 6. Bassuk E, Schoonover S. Rampant dental caries in the treatment of depression. J Clin Psychiatr 36:163-65,1975. 7. Slome B. Rampant caries: a side effect of tricyclic antidepressant therapy. Gen Dent 321494-97,1984. 8. Johnson G, Barenthin I, Westphal C. Mouthdryness among patients in longterm hospitals. Gerodontol3:197-203,1984. 9. Thorselius I, Emilson C, Osterberg T. Salivary conditions and drug consumption in older age groups of elderly Swedish individuals. Gerodontics 4:66-70,1988. 10. Osterberg T, Landahl S, Hedegard B. Salivary flow, saliva pH and buffering capacity in 70-year-old men and women. J Oral Rehabil11:157-70,1984. 11. Makila E. Oral health among inmates of old people’s homes. 11. Salivary secretion. Proc Finn Dent SOC7364-9,1977. 12. Handelman S, Baric J, Espeland M,
120 Special Care in Dentistry. Vol12 No 3 1992
13. 14.
15.
16. 17.
18.
19.
20.
21.
22.
23.
24. 25.
26.
27.
28.
29.
30.
31.
Berglund K. Prevalence of drugs causing hyposalivation in an institutionalized population. Oral Surg Oral Med Oral Pathol6226-31,1986. Physician’s desk reference. 39th ed. Oradell (NJ): Medical Economics Company, 1985. Physician’s desk reference for nonprescription drugs. 6th ed. Oradell (NJ): Medical Economics Company, 1985. Physician’s desk reference for ophthalmology. 13th ed. Oradell (NJ): Medical Economics Company, 1985. AMA drug evaluations. 5th ed. Philadelphia: WB Saunders Co, 1983. Goodman L, Gilman A, eds. The pharmacological basis of therapeutics. 6th ed. New York MacMillan, 1980. Persson R, Izutsu K, Truelove E, Persson R. Differences in salivary flow rates in elderly subjects using xerostomatic medications. Oral Surg Oral Med Oral Pathol72:42-6, 1991. Navazesh M, Christensen C. A comparison of whole mouth resting and stimulated salivary measurement procedures. J Dent Res 61:1158-62,1982. Radike A. Criteria for diagnosis of dental caries. Proceedings of the Conference on the Clinical Testing of Cariostatic Agents, October, 1968. Chicago: American Dental Association, pp 87-9,1972. Banting D, Ellen R, Fillery F. Prevalence of root surface caries among institutionalized older persons. Community Dent Oral Epidemiol8:84-7,1980. Katz R. Assessing root caries in populations: the evolution of the root caries index. J Public Health Dent 40:7-16,1980. Manderson R, Ettinger R. Dental status of the institutionalized elderly population of Edinburgh. Community Dent Oral Epidemiol3:100-7,1975. Martinello B. Oral health assessment of residents of a Chatham, Ontario home for the aged. J Can Dent Assoc 42:405-8,1976. Empey G, Kiyak H, Milgrom P. Oral health in nursing homes. Spec Care Dentist 3:65-7, 1983. Lemasney H, Murphy E. Survey of the dental health and denture status of institutionalized elderly patients in Ireland. Community Dent Oral Epidemiol 12:39-42,1984. Mann J, Mersel A, Gabai E. Dental status and dental needs of an elderly population in Israel. Community Dent Oral Epidemiol 13:156-8,1985. Saunders R, Solomon E, Handelman S. Relationship of age and tooth loss in a chronic care facility. Spec Care Dentist 2:25-30,1982. Heifetz S. Clinical trials in special care populations: some methodological issues requiring attention with limited group sizes. Spec Care Dentist 11:45-6,1991. Baker K, Levy S, Chrischilles E. Medications with dental significance: usage in a nursing home population. Spec Care Dentist 11:19-25,1991. Atkinson J, Shiroky J, Macynski A, Fox P.
Effects of furosemide on the oral cavity. Gerodontology 8:23-6,1989. 32. Christensen C, Navazesh M, Brightman V. Effects of pharmacologic reductions in salivary flow on taste thresholds in man. Arch Oral Biol29:17-23,1984. 33. Bertram U. Xerostomia: clinical aspects, pathology, and pathogenesis. Acta
Odontol Scand 49:l-29,1967. 34. Heintze U, Birkhed D, Bjorn H. Secretion rate and buffer effect of resting and stimulated whole saliva as a function of age and sex. Swed Dent J 7227-38,1967. 35. Baum 8. Evaluation of stimulated parotid saliva flow rate in different age groups. J Dent Res 60:1292-6,1981.
36. Ben-Aryeh H, Miron D, Szargel R, Gutman D. Whole saliva secretion rates in old and young healthy subjects. J Dent Res 6311147-8,1984. 37. Kitamura M, Kiyak H, Mulligan K. Predictors of root caries in the elderly. Community Dent Oral Epidemiol 14:34-8, 1986.
Special Care in Dentlstry, Vol12 No 3 1992 121
Effects of hyposalivatory medications on saliva flow rates and dental caries in adults aged 65 and older Institutionalized adults aged 65 or older often receive medications that have been associated with decreased saliva flow. Flow rates depressed by hyposallvatory medications are thought to increase susceptibility to dental caries. In this study, a crosssectional comparison was made of stimulated whole saliva rates and coronal and root caries prevalence in a group of older adults, in a long-term care facility, taking hyposalivatory medications vs. a control group. No significant differences were found between the two groups in masticatory or gustatory stimulated flow rates or in mean decayed coronal or root surfaces.
dults aged 65 and older use more hyposalivatory medications than do those in other age groups.’ A potential consequence of reduced saliva flow as a result is increased susceptibility to dental caries. Increased incidence of caries in animals and humans has been welldocumented subsequent to massive radiation to the head and neck and following surgical de~alivation.~.~ Severe decay has also been reported in case studies describing large, multiple doses of psychoactive medications with hyposalivatory proper tie^.^.^ Older adults in long-term care facilities receive many psychoactive medications as well as diuretics, GI/ urinary tract agents, antihistamines, antihypertensives, and other medications which may have hyposalivatory properties. However, few investigations have studied the extent to which the saliva flow rate is reduced in older adults taking medications and living in nursing home^.^,^ Furthermore, the effects of salivary flow reduction on dental caries prevalance and incidence have not been adequately explored. Thus, this preliminary investigation compared saliva flow rates and the prevalence of coronal and root caries in a group of older adults using hyposalivatory medications with a similar group not using these medications.
Patients and methods The subjects for the study were a dentate sample of residents of a nursing home in Rochester, NY. Study subjects were 65 years of age or older, had at least six teeth (excluding third molars), and were mentally and physically capable of participating in
116 Special Care in Dentistry, Vol12 No 3 1992
the examination sessions. Subjects with five or fewer teeth were not included, because it has been reported that saliva flow may be diminished when few or no teeth are present.lo,ll The nursing home had 219 residents. Of these, 157 volunteered to be screened for the study. Of those screened, 88 (57%)had at least six teeth and were eligible study subjects. Of the 88 eligible subjects, 57 consented to participate and became the study sample. Two samples of stimulated whole saliva (one masticatory and one gustatory) were obtained from each subject. Various stimuli for obtaining saliva were used, because the type of stimulus which produces the most representative flow has not been conclusively established in the literature. Initially, subjects were asked to place a sterilized rubber band in their mouths and to chew on the band at a steady but comfortable rate. Next, they were instructed to expectorate gently, into a plastic cup, any saliva that had accumulated in their mouths any tirpe they felt the urge to swallow, but no less often than once every 60 seconds for a period of 5 minutes. At this session, the names and dosages of all medications currently being used were recorded. Medications being used by study subjects were classified as hyposalivatory or not hyposalivatory, according to a modified method of classification established by ~ this method, Handelman et ~ 1 . ’ For information regarding all medications used by the study population was reviewed in the Physician’s Desk Referen~e’~, the Physician’s Desk
Reference for Nonprescription DrugsI4,the Physician's Desk Reference for Ophthalrnol~gy~~, AMA Drug Evaluations'b,and The Pharmacological Basis for therapeutic^'^. If xerostomia or reduction in saliva flow was a recognized effect or side-effect of a medication used by the study population, or if the medication belonged to a group recognized to have a hyposalivatory potential, the medication was classified as hyposalivatory. Recent studies*Ja,lsof older adults have quantified the use of various medications on saliva flow rates in older adults and have implicated diuretics as having significant hyposalivatory potential. Thus, the Handelman'* method of classification was modified in the current study to include diuretics. During a second-session collection period, a gustatory-stimulated saliva sample was obtained in accordance with the methods of Navazesh and By means of a sterile Chri~tensen.'~ dropper, four drops of 2% citric acid were placed on the anterior dorsal surface of the tongue at 60-second intervals. Again, subjects were instructed to expectorate gently into a plastic cup whenever they had the urge to swallow but not less often than every 60 seconds for a period of five min. Saliva flow rates were then calculated as mL/min. Study subjects were restricted from eating, drinking, and smoking for at least one h prior to saliva collection. All saliva samples were obtained between 2:OO p.m. and 4:OO p.m., the acrophase of the usual diurnal variation in flow rate. The acrophase was selected because there was concern that flow rates might be extremely low for persons taking medications at other times. Immediately after the gustatorystimulated saliva sample was obtained, the numbers of decayed and filled coronal and root surfaces were recorded. Coronal caries was described according to the criteria of Radike20and root caries according to ' two the criteria of Banting et ~ 1 . ~The examiners who recorded the study data were rated against each other (90%agreement) and against an experienced examiner (90%agree-
Table 1. Ten most common medical diagnoses in study populatlon.
Table 2. Dlstrlbutlonof hyposalivatory medications used by study populatlon.
Diagnosis No. of Subjects Hearing loss 24 Degen. joint disease 24 Arterioscleroticheart disease 17 Anxiety 15 Constipation 13 Cataracts 13 Congestive heart failure 12 Angina 11 Glaucoma 11
Diuretics Furosemide (Lasix) Hydrochlorothiazide (Esidrix) Acetazolamide (Diamox) Chlorthalidone (Hygroton) Triamterene, Hydrochlorothiazide (Dyazide) Methazolamide (Neptazane) Spironolactone(Aldactone) Sedative/ hypnotics Diazepam (Valium) Flurazepam (Dalmane) Temazepam (Restoril) Chlordiazepoxide(Librium) Triazolam (Halcion) Lorazepam (Ativan) Oxazepam (Serax) GI/urinary tract Diphenoxalate,atropine (Lomotil) Atropine, scopalamine, hyoscyamine, phenobarbital (Donnatal) Propantheline (Pro-Banthine) Metoclopromide(Reglan) Antihistamines Chlorpheniramine (Chlor-Trimeton) Meclizine (Antivert) Diphenhydramine (Benadryl) Agents for pain control Propoxyphene (Darvon) Codeine (Empirin,Codeine) Ibuprofen (Motrin) Antipsychotics/ antidepressants Trifluoperazine (Vesprin) Imipramine (Tofranil) Doxepin (Adapin) Antihypertensives Prazosin (Minipress) Chlorothiazide,Reserpine (Diupress) Captopril (Capoten) Anti-Parkinson's agents Procyclidine (Kemadrin) Carbidopa/levodopa (Sinemet) Cardiovascular agents Nadolol (Corgard)
ment) so that consistency for both coronal and root decay evaluations would be ensured.
Results The age range of study subjects was 66-93 (mean, 83.4 k 5.4 SD) years. The ratio of male to female subjects in the study population was approximately 1:6, and the mean number of teeth was 17.9 f 6.8 (SD). The numbers of teeth for males and females were 15.8 f 7.3 (SD) and 18.4 f 6.7 (SD),respectively. For the study population, 67% had at least one coronal surface with untreated caries. The mean number of decayed coronal surfaces was 2.0 f 2.5 (SD). The population had a mean of 2.7 f 3.6 (SD) decayed root surfaces. The percentage of the population affected with root decay was 70.2. The Root Caries expressed as a percentage of the total number of surfaces was 25.0 f 20.4 (SD). The mean masticatory stimulated flow rate was 0.42 f 0.36 (SD) mL/ min. The gustatory flow rate was 1.01 f 0.55 (SD) mL/min. The 10 medical diagnoses (International Classification of DiseasesClinical Modification, 1980) found most commonly in this population are listed in Table 1. None of the study subjects had Sjogren's syndrome, was receiving head and neck radiation or chemotherapy, suffered from salivary gland pathological conditions, or had any other untreated disorder identified as affecting salivary flow rate. The percentage of each hypo-
%*
18.3 4.2 4.2 1.4 1.4 1.4 1.4 %
14.1 2.8 2.8 2.8 2.8 1.4 1.4 %
5.6 2.8 1.4 1.4 %
2.8 2.8 2.8 %
4.2 1.4 1.4 %
1.4 1.4 1.4 %
1.4 1.4 1.4 %
1.4 1.4 1.4
* Total does not exactly equal 100%due to rounding.
Special Cam in Dentistry, Vol12 No 3 1992 117
Table 3. Masticatory and gustatory saliva flow rates by hyposalivatory medication use.
Masticatory
Gustatory
Flow Rate (mL/min) . .
Flow Rate (mL/min) . .
Medication Use
No. of Subjects
Subjects
None
12
21
0.61 f 0.45‘
1.12 f 0.49
Somet
45
79
0.38 f 0.32
0.98 f 0.57
NS’
NS
(Yo)
Mean f SD. Difference by medication group compared by Student’s t test. * NS = Not significant. *
Table 4. Decayed and filled coronal sutfaces by hyposalivatory medication use.
Hyposalivatory Medication Use None Some* (n = 12) (n = 45) Decayed surfaces Mean surfaces/subject
1.8 2.4+
+
2.1 f 2 . 6
NS’
Percentage of surfaces
2.2 f 2.8
3.6k5.6
NS
Mean surfaces/subject
35.5 f 19.1
35.3+ 24.9
NS
Percent of surfaces
38.2 f 16.3
43.7f 24.6 NS
Filled surfaces
*
Differences by medication group compared by Student’s t test. Mean SD. * NS = Not significant. +
*
salivatory medication is noted as a percent of the total hyposalivatory medications (Table 2). The mean duration of use of hyposalivatory medications by study subjects was 11.9 9.9 (SD) months (range, 1-50 months). Because pharmacological dosages for study subjects were not large, it is likely that the duration of medication use had more influence than dose levels on saliva flow. Table 3 presents the masticatory and gustatory saliva flow rates by hyposalivatory medication used. Seventy-ninepercent of the study subjects were taking at least one hyposalivatory medication. Those taking hyposalivatory medications had relatively low masticatory flow rates compared with those not taking them; however, the differences were not statistically significant. For gustatory flow rates, the difference between groups was less but was in the same direction (i.e., the group taking the medications had lower flow rates).
+
Decayed and filled coronal surfaces by medication used are presented in Table 4. Both mean decayed surfaces and percentage of surfaces decayed were slightly greater for those using hyposalivatory medications than for those not using them; however, these differences were not statistically significant. Filled surfaces were almost identical between the two groups. Decayed and filled root surfaces and the Root Caries Index were greater for subjects using hyposalivatory medications (Table 5). These differences were greater than those for coronal surfaces but were not statistically significant. Spearman correlation coefficients for the relationship between decayed and filled coronal surfaces and saliva flow rates are presented in Table 6. These coefficients provide no evidence of a relationship between these variables for study subjects. However, low inverse correlations were observed when the relationship between decayed and filled root
118 Special Care in Dentistry, Vol12 No 3 1992
surfaces and flow rates was analyzed (Table 7), suggesting that decreased flow rates may be accompanied by increasing levels of root decay.. The relationships with filled root surfaces and the Root Caries Index to the flow rates were statistically significant.
Discussion Thirty-one percent of the total population screened (n = 157) was edentulous. By the criteria of prevalence of edentulousness, the total population was dentally healthy; most studies of older adults in long-term care facilities have reported rates of edentulousness ranging from 60 to 90%.2D-2R The study sample was relatively small, as is frequently the case with investigations of special patient population^.^^ Possible trends toward decreased saliva flow and increased caries in subjects taking medications were observed, although differences were not statistically significant. There are significant logistical and economic obstacles to the completion of epidemiological studies in a single population of long-term care facility residents. A larger sample of institutions would be necessary for the results to be generalizable. Repeat studies or multi-center investigations are recommended. The distribution of potentially significant medical diagnoses between the two groups was similar with the exception of diabetes mellitus. All seven of the persons with diabetes were taking hyposalivatory medications. Because the impact of diabetes on saliva flow rates is not wellestablished, mean flow rates were calculated for this subgroup. The mean masticatory flow rate for subjects with diabetes, all of whom were receiving treatment if necessary, was 0.55 mL/min; the mean gustatory flow rate was 1.23 mL/min. These values were slightly higher than the means for the entire population, suggesting that individuals with diabetes in the current study were not at increased risk for low saliva flow. The mean number of medications used by study subjects was 6.5. This number is relatively high compared
with two other studies of long-term care facility popu1ations.”,l2These higher levels may be attributed to vitamins, topical preparations, and pro re nata medications included in the current study. The proportion of subjects using hyposalivatory medications (79%)was higher than that of an earlier long-term care facility survey in which diuretics were not included.12 It is similar to a recent investigatioxP that did include these medications. Definitive classification of medications by their potential to affect the perception of mouth dryness and actual decreased saliva output is difficult. Limited research in this area has produced conflicting results. For example, recent studies of long-term care facility residents8~1U,’s have reported reduced flow rates when diuretics are taken. However, five young males taking the diuretic furosemide did not have decreased saliva flow but did have an increased perception of mouth dryne~s.~’ It should be noted that, while, for statistical analysis, subjects in this study were dichotomized into those taking and not taking hyposalivatory medications, other divisions were possible that might have affected the results. However, other groupings were evaluated, including a division of subjects into those taking 0, 1, and 2 or more hyposalivatory medications, and none of these demonstrated significant differences according to gustatory or masticatory flow rates, incidence of coronal or root caries, or total number of medications used. Pharmacological effects on both stimulated and resting saliva flow rates have been investigated. Stimulated salivary flow rates were selected for this study partially because of the difficulty of collecting measurable amounts of unstimulated saliva in frail older persons. Persson et a1.18, in a study of a similar population, attempted to collect both stimulated and unstimulated samples, but they were unsuccessful in obtaining viable amounts of unstimulated saliva. Both stimulated and unstimulated flows have been found to be depressed by the use of certain medications, although the effects are probably not completely ~omparable.’,~~ A study of
Table 5. Decayed and filled root surfaces by hyposalivatory medication use.
-~ _
_
~
_
Hyposalivatory Medication Use None Some* (n = 12) = 45) (n ~ _ _
_
Decayed surfaces Mean surfaces/subject
1.8 f 2.2’
2.9f 3.8
NS*
Percent of surfaces
4.0 f 3.5
8.9k 12.6
NS
* 7.7
NS
Filled surfaces Mean surfaces/subject
8.1
4.5 f 3.6
Percent of surfaces
12.05 11.2
19.4f 19.6 NS
15.8f 12.0
27.5f21.6
Root Caries Index (RCI) (Surfaces percent)
NS
*
Differences by medication group compared by Student’s t test. Mean f SD. * NS = Not significant. +
Table 6. Correlations between decayed and filled coronal surfaces and masticatory and gustatory saliva flow rates.
Masticatory Flow Rate
Gustatory Flow Rate
p value _ ~
r*
p~ value
Decayed
-0.07
0.60
0.04
0.79
Filled
0.01
0.96
-0.21
0.10
~~
~
~
_
_
r
_
_
_
_
* Spearman Correlation Coefficient,
Table 7. Correlations between decayed and filled root surfaces and Root Caries Index and masticatory and gustatory saliva flow rates.
Masticatory Flow Rate
Gustatory Flow Rate
r‘
p value
r
p value
Decayed
-0.18
0.18
-0.17
0.20
Filled
-0.29
0.03
-0.29
0.02
Root Caries Index (RCI)
-0.32
0.02
-0.26
0.05
* Spearman Correlation Coefficient.
healthy outpatients found that stimulation reduced, but did not eliminate, the saliva-depressive effects of medication.32If this is correct, then the differences seen between subjects taking and those not taking hyposalivatory medications in the current study may have been greater if resting flow could have been measured. In one study”’ of 70-yearold persons, stimulated flow rates varied less than resting flow in response to the use of medications. Thus, the stimulated rates were thought more reliably to reflect the effects of medications. Measures of both stimulated and unstimulated flow rates of whole saliva and indi-
vidual glands may be needed to describe salivary gland function ~ompletely.’~ In 1977, Makila” investigated masticatory stimulated flow in a dentate population of a long-term care facility. Flow rates were one-third to one-half higher than those of the current study, possibly because of the greater proportion of males in that population. It is known that saliva flow rates for males are higher than those for f e m a l e ~ . ~ J ” ”In , ~the ~-~~ current study population, the percentages of males in the medication group (13%)and the non-medication group (16%)were similar, and so it is unlikely that gender differences
Smcial Care in Dentistry, Vol12 No 3 1992 119
~
disproportionately influenced the flow rates of these two groups. Whole saliva flow stimulated with citric acid in a population of older adults not living in long-term care facilities%had flow rates of 1.48 mL/ min for males and 1.28 mL/min for females. The higher rates found in that study33may be attributed to the subjects involved, who were healthier and used no medications. In our study, flow rates for both stimuli were less for subjects using hyposalivatory medications than for those not using them; however, the differences were not statistically significant. Diminished saliva flow rates have been reported in other studies8,10J8 of older adults receiving hyposalivatory medications.*JoJ8 Subjects using hyposalivatory medications had slightly higher (although not statistically significant) percentages of decayed and filled coronal tooth surfaces than those not using these medications. Three case report^^-^ in the literature have described the appearance of severe caries when high doses of single or multiple psychotropic medications have been used for therapeutic periods of up to 3 years. Persson et d . l S found no significant differences in DMFS for long-term care facility residents taking and not taking hyposalivatory medications. The results of the present study appeared to be consistent with those of an in~estigation~~ of both residents of long-term care fcilities and community-based persons in which those using medications with a definite hyposalivatory effect had more root caries than did those using none.
Summary and conclusions This article reports on a preliminary study of the relationships among hyposalivatory medication use, saliva flow rates, and dental caries in a longterm care facility population, aged 6593. Seventy-nine percent of subjects were taking hyposalivatory medications, and these patients had a higher Root Caries Index than did those subjects not taking hyposalivatory medications. Although subjects taking these medications had lower
absolute saliva flow rates and higher levels of coronal and root caries than did those not using hyposalivatory medications, these differences were not statistically significant. Because of the small sample population in this study, larger crosssectional and longitudinal investigations are needed for clarification of the extent to ,whichsignificant differences may be present. So that sufficient numbers of subjects can be enrolled, these studies should be multi-center in design. This research was supported by Grant No. P50DE07003 from the National Institute of Dental Research. Dr. Saunders is Clinical Associate and Coordinator of Geriatric Dentistry, Eastman Dental Center, and Associate Professor of Clinical Dentistry, University of Rochester, NY. Dr. Handelman is Chairman of the Department of General Dentistry, also at Eastman. Address reprint requests to Dr. Saunders, Eastman Dental Center, 625 Elmwood Avenue, Rochester, NY 14620. 1. Sreebny L, Valdini A, Yu A. Xerostomia. Part 11: Relationship to nonoral symptoms, medications, and diseases. Oral Surg Oral Med Oral Pathol68:419-27,1989. 2. Bowen W. The induction of rampant caries in monkeys (Macaca iris). Caries Res 3227-37,1969. 3. Bowen W, Pearson S, Young D. The effect of desalivation on coronal and root surface caries in rats. J Dent Res 6721-3,1988. 4. Edgar W, Bowen W, Cole M. Development of rampant dental caries and composition of plaque fluid and saliva in irradiated primates. Oral Path 10284-95, 1981. 5. Stevens J, Wilkinson E. Medications, dry mouth and dental disease. Psychomatics 12310-12,1971. 6. Bassuk E, Schoonover S. Rampant dental caries in the treatment of depression. J Clin Psychiatr 36:163-65,1975. 7. Slome B. Rampant caries: a side effect of tricyclic antidepressant therapy. Gen Dent 321494-97,1984. 8. Johnson G, Barenthin I, Westphal C. Mouthdryness among patients in longterm hospitals. Gerodontol3:197-203,1984. 9. Thorselius I, Emilson C, Osterberg T. Salivary conditions and drug consumption in older age groups of elderly Swedish individuals. Gerodontics 4:66-70,1988. 10. Osterberg T, Landahl S, Hedegard B. Salivary flow, saliva pH and buffering capacity in 70-year-old men and women. J Oral Rehabil11:157-70,1984. 11. Makila E. Oral health among inmates of old people’s homes. 11. Salivary secretion. Proc Finn Dent SOC7364-9,1977. 12. Handelman S, Baric J, Espeland M,
120 Special Care in Dentistry. Vol12 No 3 1992
13. 14.
15.
16. 17.
18.
19.
20.
21.
22.
23.
24. 25.
26.
27.
28.
29.
30.
31.
Berglund K. Prevalence of drugs causing hyposalivation in an institutionalized population. Oral Surg Oral Med Oral Pathol6226-31,1986. Physician’s desk reference. 39th ed. Oradell (NJ): Medical Economics Company, 1985. Physician’s desk reference for nonprescription drugs. 6th ed. Oradell (NJ): Medical Economics Company, 1985. Physician’s desk reference for ophthalmology. 13th ed. Oradell (NJ): Medical Economics Company, 1985. AMA drug evaluations. 5th ed. Philadelphia: WB Saunders Co, 1983. Goodman L, Gilman A, eds. The pharmacological basis of therapeutics. 6th ed. New York MacMillan, 1980. Persson R, Izutsu K, Truelove E, Persson R. Differences in salivary flow rates in elderly subjects using xerostomatic medications. Oral Surg Oral Med Oral Pathol72:42-6, 1991. Navazesh M, Christensen C. A comparison of whole mouth resting and stimulated salivary measurement procedures. J Dent Res 61:1158-62,1982. Radike A. Criteria for diagnosis of dental caries. Proceedings of the Conference on the Clinical Testing of Cariostatic Agents, October, 1968. Chicago: American Dental Association, pp 87-9,1972. Banting D, Ellen R, Fillery F. Prevalence of root surface caries among institutionalized older persons. Community Dent Oral Epidemiol8:84-7,1980. Katz R. Assessing root caries in populations: the evolution of the root caries index. J Public Health Dent 40:7-16,1980. Manderson R, Ettinger R. Dental status of the institutionalized elderly population of Edinburgh. Community Dent Oral Epidemiol3:100-7,1975. Martinello B. Oral health assessment of residents of a Chatham, Ontario home for the aged. J Can Dent Assoc 42:405-8,1976. Empey G, Kiyak H, Milgrom P. Oral health in nursing homes. Spec Care Dentist 3:65-7, 1983. Lemasney H, Murphy E. Survey of the dental health and denture status of institutionalized elderly patients in Ireland. Community Dent Oral Epidemiol 12:39-42,1984. Mann J, Mersel A, Gabai E. Dental status and dental needs of an elderly population in Israel. Community Dent Oral Epidemiol 13:156-8,1985. Saunders R, Solomon E, Handelman S. Relationship of age and tooth loss in a chronic care facility. Spec Care Dentist 2:25-30,1982. Heifetz S. Clinical trials in special care populations: some methodological issues requiring attention with limited group sizes. Spec Care Dentist 11:45-6,1991. Baker K, Levy S, Chrischilles E. Medications with dental significance: usage in a nursing home population. Spec Care Dentist 11:19-25,1991. Atkinson J, Shiroky J, Macynski A, Fox P.
Effects of furosemide on the oral cavity. Gerodontology 8:23-6,1989. 32. Christensen C, Navazesh M, Brightman V. Effects of pharmacologic reductions in salivary flow on taste thresholds in man. Arch Oral Biol29:17-23,1984. 33. Bertram U. Xerostomia: clinical aspects, pathology, and pathogenesis. Acta
Odontol Scand 49:l-29,1967. 34. Heintze U, Birkhed D, Bjorn H. Secretion rate and buffer effect of resting and stimulated whole saliva as a function of age and sex. Swed Dent J 7227-38,1967. 35. Baum 8. Evaluation of stimulated parotid saliva flow rate in different age groups. J Dent Res 60:1292-6,1981.
36. Ben-Aryeh H, Miron D, Szargel R, Gutman D. Whole saliva secretion rates in old and young healthy subjects. J Dent Res 6311147-8,1984. 37. Kitamura M, Kiyak H, Mulligan K. Predictors of root caries in the elderly. Community Dent Oral Epidemiol 14:34-8, 1986.
Special Care in Dentlstry, Vol12 No 3 1992 121
