Oral health: A broader psychosocial approach

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Sir, we are a team of researchers at Northumbria and Newcastle Universities, and read with great interest the article Oral dryness and Sjögren's: an update (BDJ 2017; 223: 649–654). One of us (HC) is a dentist, familiar with dry mouth experienced by many patients. Therefore, we agree that although dry mouth is most commonly associated with medication use, it may also be an early presenting feature of primary Sjögren's syndrome (pSS). Furthermore, we agree that the oral health implications of a reduction in saliva volume are hugely significant, and a management approach aimed at addressing these is fundamental. Indeed, guidelines recently produced by the British Society for Rheumatology for the management of adults with pSS outline an approach to oral dryness based on 'conserve', 'replace', 'stimulate', which is entirely consistent with this.¹

However, we would suggest that there is a place for an additional, broader psychosocial approach to oral dryness in terms of its impact on quality of life – specifically in relation to food and eating experience. As such, we would concur with Ní Ríordáin and Wiriyakijja's article (BDJ 2017; 223: 713–718) acknowledging the psychosocial impact of oral mucosal conditions, and highlighting patient reported outcome measures, and the challenges of capturing accurate, comprehensive representations of issues identified by patients themselves as important. Recent research with survivors of head and neck cancer explored the eating difficulties faced by patients with structural and functional changes to the mouth and jaws, and radiotherapy-induced dry mouth.² This work found that the impact on eating extends well beyond the functional, pervading all aspects of life including sensory, cognitive, emotional, social and cultural domains. Patients who struggle with food become severely restricted in their daily activities and this has a detrimental effect on their quality of life.

These findings led us to develop a theoretical model, which we named 'The Altered Eating Framework'.² The framework conceptualises and maps the range of consequences of this altered relationship with food, and as such, may be applicable to many other conditions where normal eating is disrupted. We are investigating potential applications of this model. Currently, we are exploring eating difficulties experienced by people with oral dryness associated with pSS in order to address the paucity of research into non-pharmacological interventions for this condition identified by Hackett et al.'s systematic review.³ We are developing a patient-led intervention aiming to address the impact of dry mouth on quality of life by applying the Altered Eating Framework to a mixed methods investigation of oral dryness and eating experience in people with pSS. We then aim to build a psychosocial intervention based on patient generated outcomes and perspectives.