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Palliative care
Xerostomia causes a great deal of morbidity in patients with advanced cancer. However, it is an area which
has received little attention. Indeed current management of xerostomia in palliative care units is based
largely on anecdotal evidence. There are a number of studies in progress specifically looking at patients
with advanced cancer, but until these are published we should take note of studies done in other patient
groups. This article reviews the medical literature on the symptomatic management of xerostomia as a
whole, with particular reference to treatments that are currently available in the United Kingdom.
210 # 1997 Blackwell Science Ltd, European Journal of Cancer Care, 6, 209±214
European Journal of Cancer Care
again often used to treat xerostomia (Twycross & Lack, However, this does not seem to be an issue, even in older
1986). In an uncontrolled study, a mouthwash containing patients (Aagaard et al., 1992). Chewing gum is generally
1% citric acid was found to be effective in patients with not associated with side effects (Aagaard et al., 1992;
non-radiation-induced xerostomia (Spielman et al., 1981). Risheim & Arneberg, 1993), although it may cause local
However, patients with radiation-induced xerostomia did irritation (Olsson et al., 1991).
not respond to the mouthwash. Interestingly, subjective Chewing gum appears to increase salivary flow, mainly
improvement in the sensation of dryness of the mouth was as a result of stimulation of taste receptors, although
associated with an objective increase in salivary flow in stimulation of other receptors, as a result of the act of
only 55% of cases. The mouthwash was generally well mastication, also occurs (Abelson et al., 1989).
tolerated, although three out of 34 patients had to
discontinue using it because of a burning sensation. Citric
Nicotinamide
acid, like ascorbic acid, can have a detrimental effect on
the teeth (Newbrun, 1981). Nicotinamide is one of the vitamin B group. It was also
one of the treatments in the Bjornstrom study (Bjornstrom
et al., 1990), and 35% of the patients wanted to continue
Malic acid
with the tablets at the end of the study. The tablets were
Malic acid is a naturally occurring acid found in apples, not given to patients with radiation-induced xero-
pears and certain other fruits. In the Bjornstrom study stomia because of the theoretical risk of stimulating tu-
(Bjornstrom et al., 1990), 44% of the patients wanted to mour growth.
continue with the pastilles at the end of the study, and
local irritation was not a significant problem. However,
Pilocarpine
malic acid is again known to cause demineralization of the
teeth (Anneroth et al., 1980), and so is again not suitable There have been a number of controlled studies that have
for long-term use in dentate patients. shown that pilocarpine is an effective treatment for
radiation-induced xerostomia (Greenspan & Daniels,
1987; Schuller et al., 1989; Fox et al., 1991; Le Veque et
Sweets
al., 1993; Johnson et al., 1993; Rieke et al., 1995), and
Sweets containing citric and malic acid are often used to xerostomia due to disease of the salivary glands, e.g.
treat xerostomia (Twycross & Lack, 1986). In an uncon- Sjogren's syndrome and chronic non-specific sialadenitis
trolled study, mints were found to increase salivary flow in (Fox et al., 1986, 1991). It has also been used successfully
patients with xerostomia (Abelson et al., 1989). However, in drug-induced xerostomia (Chambers et al., 1996; Salah
subjective improvement in the sensation of dryness of the & Cameron, 1996).
mouth, duration of the effect, and acceptability of the The response to pilocarpine appears to depend to a
treatment, were not recorded. certain extent on the aetiology of the xerostomia. Thus,
whilst most patients with xerostomia due to salivary gland
disease or drugs found it helpful (Fox et al., 1986;
Chewing gum
Chambers et al., 1996), only 51±54% of patients with
There have been a number of studies that have shown that radiation-induced xerostomia did (Johnson et al., 1993;
chewing gum increases salivary flow in patients with Rieke et al., 1995). Furthermore, subjective improvement
xerostomia of varying aetiology (Markovic et al., 1988; in the sensation of dryness of the mouth was not
Abelson et al., 1990; Olsson et al., 1991; Aagaard et al., necessarily associated with an objective increase in
1992; Risheim & Arneberg, 1993), although the duration of salivary flow (Johnson et al., 1993; Le Veque et al.,
the effect was not recorded. This objective improvement 1993). In most patients the response to pilocarpine is
in salivary flow was associated with subjective improve- immediate (Fox et al., 1991). However, in patients with
ment in xerostomia, and when asked 56±79% of patients radiation-induced xerostomia it may take up to 12 weeks
wanted to continue using the chewing gum at the end of for a response to be seen (Johnson et al., 1993; Le Veque et
the study (Olsson et al., 1991; Aagaard et al., 1992). Indeed al., 1993). Saliva production is greatest 1 hour after a dose,
in the Bjornstrom study (Bjornstrom et al., 1990), chewing and the increase in salivary flow lasts for about 4 hours
gum was the most preferred treatment. (Fox et al., 1991).
Chewing gum has not been used much in palliative care In a crossover study from the UK, a mouthwash
units, partly because of concerns about its acceptability. containing pilocarpine was compared to artificial saliva
# 1997 Blackwell Science Ltd, European Journal of Cancer Care, 6, 209±214 211
DAVIES Xerostomia
in patients with radiation-induced xerostomia (Davies & The mechanism by which acupuncture increases sali-
Singer, 1994). The patients generally found the pilocarpine vary flow has not yet been worked out. However, it is
more effective, and 47% wanted to continue with it after known that it causes an increase in blood flow within the
the study period. Only 18% of the patients wanted to mouth (Blom et al., 1990), and there also appears to be a
continue with the artificial saliva. significant placebo effect (Blom et al., 1992).
Pilocarpine is primarily a muscarinic agonist, although
it does have some effect on the beta-adrenergic receptors
Dietary advice
within the salivary glands (Ferguson, 1993). The side-
effects seen are mainly the result of generalized para- Patients with xerostomia can often be greatly helped by
sympathetic stimulation, e.g. sweating, headache, urinary simple dietary advice, including the types of food to try,
frequency, vasodilatation (Johnson et al., 1993; Rieke et the types of food to avoid, and increasing fluid intake
al., 1995), and their incidence is dose related. Sweating is whilst eating.
the commonest side-effect, occurring in 29±37% of
patients taking 5 mg three times a day (Johnson et al.,
CONCLUSION
1993; Rieke et al., 1995). It is also the commonest reason
for discontinuing the drug (Johnson et al., 1993). With the Xerostomia causes a great deal of morbidity in patients
doses used clinically there are no significant effects on the with advanced cancer. However, as can be seen from this
cardiovascular system. article, it is an area which has received little attention.
Indeed, current management of xerostomia in palliative
care units is based largely on anecdotal evidence (Twy-
Other parasympathomimetics
cross & Lack, 1986; Regnard & Fitton, 1995). There are a
Other parasympathomimetic drugs, including the choline number of studies in progress specifically looking at
esters bethanechol (Everett, 1975; Epstein et al., 1994) and patients with advanced cancer, but until these are
carbachol (Joensuu et al., 1993), and the anticholinesterases published we should take note of studies done in other
distigmine (Wolpert et al., 1980) and pyridostigmine patient groups.
(Teichman et al., 1987), have been used to a much lesser In the studies that have compared saliva substitutes with
extent in the management of xerostomia. saliva stimulants, patients have preferred the saliva stimu-
lants (Bjornstrom et al., 1990; Davies & Singer, 1994).
Furthermore, there is some evidence that saliva stimulants
Acupuncture
can `switch on' the salivary glands, i.e. the increase in
Although acupuncture has long been recognized as a saliva flow continues after the saliva stimulant is discon-
treatment for xerostomia in Chinese medicine (Hansen, tinued (Spielman et al., 1981; Aagaard et al., 1992; Blom et
1975), it is only relatively recently that it has been adopted al., 1992). Therefore, patients should be routinely managed
by Western medicine. In a controlled study from Sweden, with saliva stimulants, rather than saliva substitutes. The
acupuncture was found to be effective in patients with choice of saliva stimulant will depend on a number of
xerostomia of varying aetiology (Blom et al., 1992). The factors, including the aetiology of xerostomia, the patient's
active group received traditional Chinese acupuncture general condition and prognosis, the presence or absence of
utilizing local, distant and auricular points, whilst the teeth and, most importantly, the patient's preference.
control group received `placebo acupuncture', i.e. super- Chewing gum is effective and well tolerated, and may be
ficial needling, 1±2 cm from these points. Each group a good first line treatment (Bjornstrom et al., 1990).
received a 6-week course of twice weekly treatments, Patients with xerostomia often receive a number of
which was repeated after a gap of 7±10 days. Interestingly, other treatments (e.g. antifungals, antiseptics, local an-
increases in salivary flow were seen in both groups, algesics) as part of a general mouthcare package. However,
although they were more pronounced and longer lasting these products will become redundant if there is an
in the active group. Indeed, the increase in salivary flow increase in salivary flow. Furthermore, some of them,
continued for at least a year in the active group, whilst it e.g. chlorhexidine gluconate and benzydamine hydrochlor-
only lasted for the period of the study in the placebo group. ide, may themselves cause xerostomia (Sonis et al., 1985).
Subjective improvement in xerostomia was not recorded. Thus, patients with xerostomia should be assessed
The acupuncture was associated with other positive regularly and their treatment altered accordingly.
effects, e.g. patients `felt better', and there were few side- As mentioned at the beginning of this article, only
effects, i.e. haematomas, tiredness after treatment. treatments that are currently available in the United
212 # 1997 Blackwell Science Ltd, European Journal of Cancer Care, 6, 209±214
European Journal of Cancer Care
Kingdom have been reviewed. However, there are a salviary gland dysfunction. Oral Surgery, Oral Medicicne, Oral
Pathology 61, 243±248.
number of other treatments available elsewhere in the Fox P.C., Atkinson J.C., Macynski A.A. et al. (1991) Pilocarpine
world, or still under development, which also show treatment of salivary gland hypofunction and dry mouth
promise in this condition. (xerostomia). Archives of Internal Medicine 151, 1149±1152.
Greenspan D. & Daniels T.E. (1987) Effectiveness of pilocarpine in
postradiation xerostomia. Cancer 59, 1123±1125.
Greenspan D. (1990) Oral complications of cancer therapies.
Acknowledgements
Management of salivary dysfunction. NCI Monographs 9, 159±
I would like to thank Denise Brady and the other members 161.
Hansen J.E. (1975) Acupuncture in otolaryngology. American
of staff in the library at St Christopher's Hospice for Journal of Chinese Medicine 3, 281±284.
obtaining the often obscure references for this article. Jobbins J., Bagg J., Finlay I.G., Addy M. & Newcombe R.G. (1992)
Oral and dental disease in terminally in cancer patients. British
Medical Journal 304, 1612.
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