Disorders Of The Oral Cavity In Parkinsons Disease And Parkinsonian Syndromes
1Department of Neurology, Movement Disorders Unit, Tel Aviv Medical Center, 6423906 Tel-Aviv, Israel
2Neurology Department, Soroka University Medical Center, 84101 Beer Sheva, Israel
3Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Awareness of nonmotor symptoms of Parkinson’s disease is growing during the last decade. Among these, oral cavity disorders are, although prevalent, often neglected by the patients, their caregivers, and physicians. Some of these disorders include increased prevalence of caries and periodontal disease, sialorrhea and drooling, xerostomia, orofacial pain, bruxism, and taste impairment. Though many of these disorders are not fully understood yet and relatively few controlled trials have been published regarding their treatment, physicians should be aware of the body of evidence that does exist on these topics. This paper reviews current knowledge regarding the epidemiology, pathophysiology, and treatment options of disorders of the oral cavity in Parkinson’s disease patients.
The pathogenesis of these disturbances in PD may be multifactorial: some disorders occur due to general motor impairment and hypokinesia ; others may be a manifestation of involuntary movements , due to medication , as a part of sensory dysfunction , or in relation to depressive symptoms .
2. Dental Caries and Periodontal Disease
3. Sialorrhea and Drooling
5. Orofacial Pain and Burning Mouth Syndrome
How Do You Know If You Or Your Loved One Has A Problem With Swallowing
Swallowing difficulties can start very subtly and initially not be obvious to either the person with PD or their loved ones. There are signs to look out for before swallowing difficulty becomes overt . Some of the signs you should pay attention to include:
- Slow rate of eating – people with difficulty swallowing may slow down their eating in order to avoid coughing or choking
- Fatigue during eating or decreased enjoyment of food
- A sensation that food is “sticking” in the throat
- Coughing or excessive throat clearing during eating
- Difficulty in swallowing pills
- Unexplained weight loss– people with difficulty swallowing may reduce their consumption in an attempt to eat without coughing or choking
- Change in dietary habits – people with difficult swallowing may alter their diet in order to avoid foods that cause difficulty. This may not be a choice made consciously
- Diagnosis of a pneumonia – this could be caused by aspiration, or entry of a foreign substance into the airway
If you think there might be a swallowing issue, it is important to speak with your doctor about it. There are steps you can take to properly assess the situation and improve your swallowing function. This can in turn reduce your risk of choking, make eating more enjoyable, and lessen the chances of unwanted weight loss and/or other discomforts.
Swallowing Exercises Can Be Very Helpful To Improve Your Swallowing
After a formal swallow assessment, swallowing therapy sessions can be designed for you, involving exercises tailored to the specific parts of your mouth and throat that are causing the swallowing problem. Sessions may involve practicing compensatory swallowing strategies with various types of foods in order to maximize safety and efficiency while swallowing.
During swallow therapy, recommendations may include:
- Best feeding techniques
- Exercises to strengthen oral and throat muscles
- Compensatory techniques to assist in safe swallowing
- Oral and mouth care techniques
- Appropriate food selection and ways to modify food texture
- Safe positioning strategies
Oral Dysfunction In Parkinsons: Swallowing Problems And Drooling
Two common and distressing problems that can develop in Parkinson’s disease are swallowing dysfunction and drooling. I want to help you better understand these issues and learn what you can do to improve them – so read on!
Thank you to Christine Sapienza, PhD, CCC-SLP and Bari Hoffman Ruddy, PhD, CCC-SLP for providing some of the material below.
Q: How Can Occupational Therapy Treatment Improve Oral Health
Occupational therapists specialize in improving fine motor control with exercise and adaptive modifications. By following instructions and recommendations from your occupational therapist, you can improve your ability to perform oral care and many other common daily activities . Consider asking your doctor for a referral to an occupational therapist to see if there are ways to improve your ability to brush and floss your teeth.
Incorporating adaptive tools into your dental routine can also improve your oral care. For example, electric toothbrushes are an easy way to incorporate adaptive tech into your daily routine. As an added bonus, many of these toothbrushes have handles that are easier to hold and grip. A number of electric toothbrushes offer timers that beep every 30 seconds to remind you to move on to another “quadrant” of your mouth so you brush for the recommended length of two minutes.
Another simple way to alleviate symptoms of dry mouth is to stay properly hydrated. Every healthy adult should drink 8 to 10 pint sized glasses of water each day in addition to incidental liquids obtained through food and other sources.
Keep a water bottle with a tight fitting lid nearby so you can take small sips throughout the day to increase your water intake. This additional hydration will also improve medication efficiency and potentially improve symptoms of orthostatic hypotension .
What Are Home Remedies And Treatment Options For Dry Mouth
Those seeking treatment for dry mouth will most likely want something to provide comfort and relief. Most are over-the-counter remedies. Treatment for dry mouth can be divided into the following four categories: saliva preservation, saliva substitution, saliva stimulation, and prevention of caries, and yeast infection.
Saliva preservation: If salivary content is low, one must do as much as possible to keep the oral tissues as moist as possible and limit the things that can dry the mouth out. Those experiencing dry mouth should try to breathe through their nose as much as possible, and limit mouth breathing. Avoiding caffeine, alcohol, and tobacco is very important. Using a humidifier to introduce more moisture to a room or at bedside can be helpful, especially while sleeping. Don’t use OTC antihistamines or decongestants, as they can dry the mouth out as well.
Saliva stimulation: Chewing gum can help stimulate salivary flow, but it is important to remember not to use gum or candies that have sugar in them or the person will be placed at greater risk for developing cavities. Sugar-free lemon drops, lozenges, or other hard candies can also help stimulate the salivary glands. Other remedies include medications that help increase salivary flow such as pilocarpine and cevimeline . These prescription medications are to be avoided by people with asthma or glaucoma.
Will My Parkinsons Mean I Need To See A Specialist Dentist
It’s important to tell your dentist that you have Parkinson’s and how it affects you.
Most dentists will be able to treat people at all stages of the condition.
If your dentist feels you need specialist care, they will refer you to a colleague on the General Dental Council’s ‘special care’ register.
If you have to have dental surgery, talk to your dentist about Parkinson’s symptoms you experience and how these may affect your operation.
You should also tell your dentist about your drug regime so that you continue to get the right dose when you have your operation.
If you’ve had deep brain stimulation and you now need to have a dental operation, you will need to take antibiotics. This will help make sure that you don’t get an infection or another issue that could affect your deep brain stimulation device.
If you wear dentures Parkinson’s may mean you have difficulty controlling them. This could be because of:
- problems controlling your facial muscles
- loss of muscle tone
What Future Medications May Be Available For Parkinsons
There are numerous studies investigating new treatments for Parkinson’s disease.
There has been new information about the role of autoimmunity and T-cells in the development of Parkinson’s disease, possibly opening the door to a role for biologics.
Stem cells are also being investigated as a treatment option for Parkinson’s disease.
Medications That Can Cause Gum Swelling And Overgrowth
A condition called gingival overgrowth or hyperplasia can result from taking certain kinds of medications. In the worst cases, the gum tissue may become so swollen that it expands over the teeth — which is not only unpleasant to look at but can lead to difficulties with chewing if it progresses.
In addition, gums which are deformed make it very difficult to clean the teeth effectively, thus allowing plaque to build up. In turn, this process gradually leads to gum inflammation , which may then cause a deterioration in the structures that support the teeth and possible loss of teeth.
This side effect of medication is more common in men and already having dental plaque also increases the risk that you will develop gum disease as a result of medication.
A build-up of gum tissue can be caused by the following medications.
Phenytoin, a seizure medication
Gingival hyperplasia secondary to drugs was first reported in the dental literature in the early 1960s; it was observed in children in residential care who were suffering from epilepsy and who were being given the anti-epileptic medication phenytoin to manage seizures.
Cyclosporine, an immunosuppressant drug often used to prevent organ rejection in people who have received a liver, kidney, or heart transplant
Blood pressure medications
Q: How Do Botulum Toxin Injections Affect Oral Health
In some instances, medications can be prescribed to control excessive saliva or drooling for people with Parkinson’s. Sometimes these medications are not effective enough to satisfactorily control drooling. In that case, your physician might suggest injections of botulinum toxin. Small amounts of botulinum toxin are injected directly into the salivary glands inside the mouth in order to temporarily shut down saliva production. Typically, botulinum toxin is injected into the parotid glands and/or the submandibular glands. Parotid glands are activated during chewing and submandibular glands produce a significant amount of saliva . These injections can be an effective approach to addressing drooling and can provide relief for up to 3 months at a time. Another benefit may include keeping dentures properly sealed and reducing breakdown of the skin in the corners of the mouth.
Occasionally this approach can simply be “too effective” at reducing saliva production, causing dry mouth. As previously outlined in this article, dry mouth caused by lack of saliva can have a negative impact on oral health.
Suck on sugar free hard candies or chew sugar free cinnamon gum to initiate saliva production.
How Do Health Care Professionals Diagnose Dry Mouth
When dry mouth is observed, the dentist can be helpful in determining the cause of dry mouth and obtaining a proper diagnosis. The diagnosis will help in developing a plan for management and treatment. The dentist will inspect the main salivary glands and ducts to check for blockages and may measure both stimulated and unstimulated salivary flow. The lips, tongue, and oral tissues will all be inspected for dryness. Sometimes a patient will still complain of dry mouth even if salivary flow is adequate. Since the symptoms of dry mouth vary greatly from individual to individual, treatments vary. Sometimes treatments are given for prolonged, chronic complaint of dry mouth, even without clinical signs of changes within the mouth. The dentist can be an important resource for specific information to manage dry mouth.
All About Dry Mouth: Causes Symptoms And Treatments
While dry mouth might initially sound like nothing more than a minor inconvenience, it can potentially lead to several other oral health concerns when left untreated. Saliva plays an important role in our mouths; it keeps the mouth moist, aids in digestion, and helps control bacteria that reside in the mouth. Dry mouth, then, results from a lack of appropriate saliva production. Besides being uncomfortable, dry mouth can lead to tooth decay, gum disease, and an increase in mouth infections. Are you suffering from dry mouth? Read on to learn more about the causes, symptoms, and treatments for this common condition.
If You Have Swallowing Difficulty What Can Be Done
In some cases, swallowing function varies in response to dopamine medication doses, much like other aspects of motor function. Therefore, if swallowing becomes problematic, an increase in dopaminergic medications can be tried. In addition, make sure you undergo a swallow evaluation when you are in the ON state.
Even before a formal swallow study, you can take steps to increase the efficiency of your swallow. These include:
- Sit upright during all eating and drinking, even when taking pills
- Tilt the head slightly forward, not backward, as you swallow
- Take small bites of food, chew thoroughly, and do not add any more food until everything from the first bite has been swallowed
- Take small sips of liquid
- Concentrate while moving the food backward in the mouth with the tongue
- “Double swallow” if the food did not go down completely with the first swallow
- Sometimes taking a sip of liquid between bites of food can help to wash the food down
- If eating is very tiring, try several smaller meals spaced out during the day instead of three large meals.
Swallowing Difficulties And Parkinsons Medication
If swallowing tablets or capsules becomes difficult, it may be tempting to crush tablets or open capsules, but this should never be done, as it can cause serious side effects and/or prevent the medication working properly. Always ask your pharmacist or doctor, or check the patient information leaflet before tampering with medicines in any way. Swallowing medications with jelly, yoghurt or apple sauce may help you swallow medication more comfortably.
Many Parkinson’s medicines are prepared or designed to work in a particular way that will be harmed by crushing or opening capsules. For example, some medicines have:
- Sugar or film coating: This is usually to make them taste better, but crushing may make them taste unpleasant.
- Enteric coating: This coating is designed to keep the tablet whole in the stomach, in some cases to protect the stomach or to protect the medicine from stomach acid so that it is released after passing through the stomach, for example in the intestine. This type of tablet should never be crushed.
- Modified or controlled release: These medications have been designed to release slowly and act over a longer period, so they can be taken less often. Crushing this type of tablet would lead to a rapid release of the medicine which could be harmful.
If you experience any problems you should talk to your doctor, so that he or she can prescribe medication in a form that is easier to take. Some medicines are available in liquid form.
What Causes Dry Mouth In People With Parkinson’s
Dry mouth can be caused by several factors including:
- Medications: Prescription and over the counter medicines are some of the most common causes of dry mouth. Reducing, stopping or changing certain medications can relieve dry mouth.
- Age: Advanced age alone is not a cause of dry mouth but half of those over age 60 take multiple maintenance medications that can trigger it.
- Medical conditions: Diabetes, Sjögren’s Syndrome and Parkinson’s disease can all cause you to experience dry mouth.
There are several connections between Parkinson’s disease and dry mouth. Repeated swallowing consumes the available saliva that keeps the mouth moist. It is often related to the drugs used to manage PD, particularly anticholinergics. A physician may be able to change or adjust medications and dosages to reduce dry mouth.4
Groups Of Medications That Can Cause Gum Disease Ear, Nose, Throat, and Dental problems
The goal of medicines is to make you be better and feel better. However, all substances, whether taken by orally or intravenously, have the potential to bring side effects. Medications used to treat cancer, hypertension, severe pain, depression, allergies, and even a simple cold, can all impact negatively your oral and dental health.
Some medications can cause your gums to swell or cause other reactions in the soft tissues. Other medications can lead to a dry mouth , loss of bone, and candidiasis or ultimately periodontitis.
Medications That Can Cause Soft Tissue Reactions
The prescription drugs listed below can lead to soft tissue discoloration, ulcers or mouth sores and inflammation , which can progress to periodontitis:
- Oral contraceptives
- Particular chemotherapy medications
If you are taking any of these medications, inform your dentist so they can advise how to reduce the discomfort.
Managing dental health and Parkinson’s is an integral part of living well. Regular dental care can minimize your risk of experiencing pain and discomfort, but most importantly, it can reduce the risk of infection, which can be a significant stressor on the body when coupled with Parkinson’s-related challenges.
In this post, we provide essential information and tools so you can learn more about dental health and Parkinson’s and improve your dental health.
Inflammation Of The Lining Inside Of The Mouth
Mucositis is inflammation of the moist tissue lining the mouth and digestive tract. This tissue is called the mucous membrane. Mucositis is a common side effect of chemotherapy treatment. Doctors think that certain chemotherapy drugs, including methotrexate and 5-fluorouracil, trigger a complex pattern of biological changes that damage the cells that make up the mucous membranes. Mucositis causes painful swelling of the mouth and tongue and can lead to bleeding, pain, and mouth ulcers. The condition can make it difficult to eat.
You are more likely to develop mucositis after taking chemotherapy drugs if you drink alcohol, use tobacco, do not take care of your teeth and gums, are dehydrated, or have diabetes, HIV, or kidney disease.
Chemotherapy medicines that can cause mucositis include:
Swallowing Difficulties In Parkinsons Disease
The act of swallowing involves a complex series of activities that begin in the mouth, continue in the pharynx and end in the esophagus. These include chewing, using the tongue to move the bolus of food to the back of the throat and then coordinating the muscles that both propel the food into the esophagus and protect the airway or trachea from food penetration. Swallowing dysfunction can be considered both a motor and a non-motor symptom of PD. Loss of dopamine neurons in the substantia nigra area of the brain can cause the motor dysfunction that impairs swallowing. However, loss of neurons in other areas of the brain, such as the cortex and lower brain stem can also affect the overall control and coordination of swallowing, and can be thought of as a non-motor symptom of PD. Swallowing issues are very important to diagnose. Impacts on your daily life and your health can range from difficulties with meals to more extreme cases where it could lead to choking and aspiration which can be very serious or even fatal.
Eating Swallowing Problems And Saliva Control
Eating and swallowing problems, known as dysphagia, occur in many medical conditions and become more common as we get older.
The main risks associated with swallowing problems are:
- Choking or asphyxiation: When food blocks the airway, preventing breathing. Also, when food or liquid enter the airway below the level of the vocal cords.
- Aspiration pneumonia: When food or liquid enter the lungs, this may cause a lung infection.
- Increased secretion: As a reaction to food or liquid entering the lungs.
- Dehydration: Lack of fluids can lead to problems such as constipation.
- Malnutrition: Lack of nourishment leads to poor health and harms the body’s ability to fight infection.
- Drooling: decrease in mouth sensitivity and / or a reduction in the frequence of swallowing saliva can cause drooling.
- Difficulties in swallowing medications.
Eating And Swallowing Problems And Parkinsons
Research suggests that eating and swallowing difficulties affect about a 90% of all people with Parkinson’s. The true figure may be even higher as some people do not report the problem to their health care team.
Swallowing is a motor function that includes three stages.
- The first stage is the oral phase: food is chewed and mixed with saliva to form a soft ball called bolus. The tongue then pushes the bolus to the back of the mouth, triggering the swallow reflex.
- The second stage is the pharyngeal phase: it is the involuntary closure of the larynx by the epiglottis and vocal cords, which temporarily inhibites breathing. These actions prevent food from going ‘down the wrong pipe’ into the trachea .
- The third stage is the esophageal phase: the bolus moves into the esophagus, the muscular tube that contracts to push the bolus into the stomach.
Unfortunately, many people with Parkinson’s experience swallowing problems due to reduced control and muscle tone of the jaw, lips, tongue and throat muscles, especially in later stages of the condition. Eating and swallowing becomes slower and requires more effort.
People with Parkinson’s are at particular risk of aspiration due to a delay in the triggering of their swallow reflex. This compromises the effectiveness of the airway protection while swallowing. This can lead to aspiration pneumonia due to a lack of coughing if food enters the windpipe, allowing food to reach the lungs unchecked.
Increasing The Flow Of Saliva With Dry Mouth
If you have dry mouth, your doctor may also prescribe an oral rinse to restore mouth moisture. You can get these products over the counter in a rinse or spray. And there are toothpastes, mouthwashes, and moisturizing gels just for dry mouth; ask your dentist or doctor about them. If that doesn’t help, they may prescribe a medication that boosts saliva production called Salagen. Another prescription drug, Evoxac, is FDA-approved to treat dry mouth in people with Sjögren’s syndrome, an autoimmune disease linked to dry eyes, dry mouth, dry skin, and muscle pain.
Finally, promising new treatments are being studied. Scientists are working on ways to repair salivary glands that have been damaged and are developing an artificial salivary gland that can be implanted into the body.
What Are The Most Common Causes Of Dry Mouth
Dry mouth happens when something causes the salivary glands to produce less saliva. The most common causes of dry mouth are:
Hundreds of medications can reduce your body’s saliva production. If you check the information that comes with your medication, you may see “dry mouth” listed as a side effect.
Some medicines known to cause dry mouth include:
Other causes include:
- Dehydration: Sometimes, your body lacks enough fluids. For example, if you’re sick, don’t drink enough, or sweat a lot, you may get dehydrated.
- Mouth-breathing: You may breathe through your mouth at night, especially if you have a stuffy nose .
- Medical conditions: Dry mouth can be a sign of a more serious condition, such as diabetes, Alzheimer’s disease, stroke and Sjogren’s syndrome. Sjogren’s syndrome is an autoimmune disease that causes the body to attack the glands that produce moisture. It occurs mostly in women who have gone through menopause.
Excessive Saliva And Drooling In Parkinsons
Saliva is needed for the first stages of digestion, including chewing and swallowing. This watery substance contains enzymes that start to digest our food.
Many people with Parkinson’s experience poor saliva control, which may result in excessive saliva and drooling, or alternatively, in a dry mouth and other eating problems.
Treating Eating And Swallowing Difficulties
If you or someone you care for is experiencing difficulties with eating, swallowing or saliva control, the first step is to consult your doctor, who may refer you on to an SLT / SLP.
Your doctor may be able to adjust the timing and dose of medicines so that these are working well at mealtimes and so swallowing problems are better managed when eating. However, for some patients, medications do not affect the swallowing function.
Your doctor may also adjust your medications, or may prescribe new ones to reduce production of saliva. Some Parkinson’s medicines, including levodopa, improve muscle movement and may help to reduce drooling. However, some medications, such as clozapine, which is prescribed for mental health problems, can actually increase saliva production.
Botulinum toxin can be injected into the salivary glands to reduce saliva production. This treatment will not work for everyone and injections may need to be repeated every three to six months. However, for some patients, Botox injections are not recommended and may be dangerous.
In severe cases when other treatments are not effective, radiotherapy to the salivary glands can restrict saliva production. In extreme cases the salivary glands can be surgically removed as a last resort.
Slow Muscles Carrying Food To Your Stomach
Parkinson’s may also slow down the muscles carrying food down into your stomach. Food moving slowly down your food pipe to your stomach can make you feel full up. But once it arrives at your stomach you realise you’re still hungry. By this time the food on your plate may have gone cold and be unappealing.
Q: How Can Medications Improve Oral Health
Generally speaking, medications for Parkinson’s can improve oral care and oral health by improving movement and motor control. These medications allow people with Parkinson’s to move with more precision and less effort which facilitates better oral care. Deep brain stimulation treatment often provides a similar effect by improving movement that can lead to better oral care.
There are no specific medications prescribed directly to improve oral health. However, your dentist may recommend special oral care devices, as well as specialized toothpastes or oral rinses. For example, an oral rinse called chlorhexidine gluconate can be very effective when used in conjunction with brushing and flossing. Chlorhexidine is preferable to many over the counter mouthwashes because it does not contain alcohol, which can exacerbate symptoms of dry mouth and irritate oral tissues. Please note that this oral rinse requires a prescription from your dentist.
What Can I Do At Home To Treat Dry Mouth
Oral hygiene is essential if you have a dry mouth. Brush your teeth twice a day, and use mouthwash. Doing so will help prevent tooth decay. Cavities and decay are more common for people with dry mouth.
It’s also important to promote saliva production. Saliva protects your mouth and teeth from decay and disease. Some dry mouth remedies can help you produce more saliva and improve symptoms.
Chewing and sucking help stimulate saliva flow. Try:
- Ice cubes or sugar-free ice pops.
- Sugar-free hard candy or sugarless gum that contains xylitol.
- Water or other sugarless fluids, sipped frequently throughout the day.
These products may also help:
- Artificial saliva products to help you produce more saliva. These products are often available over-the-counter as a rinse or spray.
- Toothpastes and mouthwashes specially made for dry mouth.
- Lip balm.
- Cool-mist humidifier, especially if you breathe through your mouth at night.
Try to avoid:
- Acidic, spicy, salty, dry and sugary foods and beverages.
- Alcohol, caffeine and carbonated drinks.
- Mouthwashes with alcohol or peroxide, which may dry your mouth even more.
Preventing Tooth Decay Due To Dry Mouth
Not only does saliva help digest food and make it possible for you to chew and swallow, it is the natural mouth cleanser. Without saliva, tooth decay and gum disease are more likely. If you have a dry mouth, to fight tooth decay and gum disease, you need to be extra careful about following good oral hygiene habits, which consist of:
- Brushing your teeth at least twice a day , after every meal and before bedtime
- Flossing your teeth every day
- Using a toothpaste that contains fluoride
- Visiting your dentist for a checkup and cleaning at least twice a year; your dentist may recommend a daily fluoride rinse or fluoride gel to keep your teeth healthy.
Eating Swallowing And Saliva Management
Some people with Parkinson’s may find they have difficulties with eating, swallowing and saliva control at some stage of their journey with Parkinson’s.
Parkinson’s can cause the muscles in the jaw and face to become stiff which affects the control of chewing and swallowing.
Medications That Can Impair Your Memory
Medications affecting memory may not at first glance seem to have anything to do with dental health. However, using such medications can lead to tiredness, lack of motivation, and even forgetfulness, so it is important to find ways to remember your dental hygiene routine; you could perhaps set an alarm or make yourself reminder notes. Brush and floss your teeth regularly and don’t forget to have regular dental inspections.
Taste Changes Including Metallic Taste
Sometimes, a medication can alter your sense of taste. A change in the body’s ability to sense tastes is called dysgeusia. Some drugs can make food taste different, or they can cause a metallic, salty, or bitter taste in your mouth. Taste changes are especially common among elderly patients who take multiple medications.
Usually the taste changes are temporary and go away when you stop taking the medicine.
Chemotherapy drugs, including methotrexate and doxorubicin, are a common cause of taste changes.
Many other medicines have been linked to taste changes. They include:
Pilocarpine / Cevimeline For Dry Mouth 18 Replies
Parkinson’s causes the GI tract to dry out from one end to the other. So I get dry mouth, pills are prone to getting stuck in my esophagus halfway down, and constipation. Stool softener works great for the constipation. For the dry mouth I have a whole array of mouth moisteners and hard candies. Even so I sometimes end up with a sore tongue from lack of saliva.
The official use of pilocarpine is to trigger the production of saliva in cancer patients, however a doctor can prescribe it for PD if s/he sees fit. It works, but there are downsides: it is short acting and only lasts for a few hours. Also, if I take a bit too much I end up with a hot flash – a feeling of heat coupled with a cold sweat, particularly if taken before bed.. My sensitivity varies – sometimes the 5mg dose is right, sometimes I need to split the tiny 5 mg pill with a pill splitter. It’s not perfect, but I do find it is helpful, and thought it was worth sharing.
Update: since posting this I have switched to Cevimeline which costs more but is less prone to the cold sweat side effect.
Bottom line is you have to do as much as necessary to moisturize that mouth cause sore tongue really occupies your attention if it gets unhappy.