Dental Tribune United Kingdom Edition

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In this context the primary post-diagnosis requi- site in all disease management/ treatment must be an accurate assessment of the initial severity of the condition. The challenge then is to create a gauge or ‘yard- stick’, against which to measure the treatment’s success. In mu- cosal disorders involving either hypo-salivation or dehydration it is also necessary to distinguish between pathological and physi- ological causes, which have been one focus of the work at the Guy’s Hospital Dry Mouth Clin- ic. (Guy’s & St. Thomas’ NHS Foundation Trust). Evidence suggests that per- haps 20 per cent of the popula- tion suffers from a dry mouth, and numbers are growing as more and more medication is prescribed which has the side effect of reducing salivation. There are more than 1,000 drugs in the BNF (British National Formulary), including those for treating high blood pressure, diuretics, anti-depressants, anti- histamines and many others, which impact gland secretions or affect glandular nerve im- pulses and lead to a 25 per cent reduction in the flow of saliva. When more than one drug is prescribed, the problem can be exacerbated by up to 75 per cent, and prescribing clinicians are notalwaysfullyawareofthecom- bined effect on oral lubrication. Patients referred to the Guy’s Hospital Dry Mouth Clinic may undergo tests for Sjogren’s syn- drome, the most common au- toimmune condition after rheu- matoid arthritis, but which is often unrecognised. In Sjogren’s syndrome, white blood cells at- tack the tear and saliva glands, causing a dry mouth and dry eyes. Women, who are most commonly affected, may also suffer vaginal dryness. The Guy’s Hospital Dry Mouth Clinic team is participating in a major, multi-national study of Sjogren’s syndrome to widen understand- ing of the condition. Having confirmed xerosto- mia, the clinician must then de- termine the severity of the con- dition and whether treatment is required. Applying the Chal- lacombe Scale measures the acuteness of the aridity relative to the saliva flow and mucin den- sity. The Scale has been proven over two years of clinical appli- cation and provides a common reference point for use between clinicians, as well as indicating treatment options. While a high score is a clear indication that treatment is needed, the more radical option with a low score is not to intervene, which can be a demanding decision and often requires specialist knowledge. An additional benefit of the Challacombe Scale is that the patient’s progress can be moni- tored over time, measuring the efficacy of treatment or indeed introducing treatment in the event of deterioration. Widespread lack of aware- ness among both clinicians and the general public has led to a frequent failure to diagnose and treat dry mouth, especially in the older demographic. The misconception persists that age is a major contributory factor, despite the fact that over half (55 per cent) of octogenarians are receiving medication which re- duces saliva flow. Experience at Guy’s has shown that age need not be a factor, and dryness can be resolved by stimulation with- in this age group. Conversely, some patients may only need to be encouraged to drink water more frequently but it is vital to recognise the difference be- tween a lack of hydration and lu- brication – water wets but does not lubricate. Many clinicians regard the mouth as merely the entrance to the alimentary canal without appreciating its importance as a primary herald for systemic diseases of the immune system, HIV, the stomach and the skin et al, and Professor Challacombe believes dental training needs to sharpen its focus on recognising these symptoms. The traditional, and in many instances persisting, role of an NHS dentist has been to pur- sue a ‘drill and fill’ policy since the system of remuneration has discouraged a comprehensive oral examination. Patients are themselves more likely to con- sult their GP for non tooth re- lated oral symptoms on grounds of cost. Nevertheless, the den- tist is usually better qualified to give a diagnosis, although the importance of access to the pa- tient’s medical history needs to be stressed when prescription drugs are involved, to allow an understanding of the difference between ‘wetness’ and ‘lubrica- tion.’ This difference can be cru- cial when deciding whether to offer a saliva substitute. The Challacombe Scale is not intended as a research tool but as a practical, empirical measure for dental profession- als to assess the severity of dry mouth syndrome and to help them determine when treatment is required. The composition of saliva includes protein, and lubrication is also necessary throughout the length of the oesophagus to facilitate swal- lowing, and so wetting alone is not a solution in severe cases. Research at the Guy’s Dry Mouth Clinic has confirmed that a 30 micron layer of mucin is nec- essary to maintain a smoothly functioning, healthy oral cavity. By introducing a reliable, proven system of reference to this important but currently under-recognised area of oral health the Challacombe Scale offers practitioners an opportu- nity to discuss the problems of a dry mouth with patients who may have become resigned to the discomfort as a consequence of their medication, or in the mistaken belief that nothing can be done as they are simply get- ting older. A.S. Pharma is proud to be associated with this important work and Professor Challa- combe’s pioneering scale. For further information, please contact A S Pharma on telephone 08700 664 117 or email: info@aspharma.co.uk DT The ‘Challacombe’ Scale A S Pharma discusses the severity and diagnosis of dry mouth About the author Professor Stephen Challacombe of King’s College, London and Guy’s Hos- pital Dry Mouth Clinic, has developed the Challacombe Scale as a universally applicable calibration system to assist in the diagnosis, measurement and treatment of xerostomia, or dry mouth as it is more commonly called. It is the result of ten years’ work head- ed by Professor Challacombe who has published or co-authored over 350 peer reviewed papers on mucosal im- munity, immunological, dermatologi- cal and microbiological aspects of oral diseases and is recognised as one of the leading experts in this specialist field. ‘Evidence suggests that perhaps 20 per cent of the population suffers from a dry mouth, and numbers are growing’