Xerostomia

Xerostomia (also termed dry mouth[1] as a symptom or

dry mouth syndrome[2] as a syndrome) is dryness in the
mouth (xero- + stom- + -ia), which may be associated with
a change in the composition of saliva, or reduced salivary
ow (hyposalivation), or have no identiable cause.

cay is a common feature and may progress much

more aggressively than it would otherwise (rampant
caries). It may aect tooth surfaces that are normally spared, e.g., cervical caries and root surface
caries. This is often seen in patients who have had
radiotherapy involving the major salivary glands,
termed radiationinduced caries.[9]

This symptom is very common and is often seen as a

side eect of many types of medication. It is more common in older people (mostly because this group tend to
take several medications) and in persons who breathe
through their mouths (mouthbreathing). Dehydration,
radiotherapy involving the salivary glands, and several
diseases can cause hyposalivation or a change in saliva
consistency and hence a complaint of xerostomia. Sometimes there is no identiable cause, and there may be a
psychogenic reason for the complaint.[1]

Oral candidiasis - A loss of the antimicrobial actions of saliva may also lead to opportunistic infection with Candida species.[9]
Ascending (suppurative) sialadenitis an infection
of the major salivary glands (usually the parotid
gland) that may be recurrent.[3] It is associated with
hyposalivation, as bacteria are able to enter the ductal system against the diminished ow of saliva.[7]
There may swollen salivary glands even without
acute infection, possibly caused by autoimmune
involvement.[3]

Denition

Xerostomia is the subjective feeling of oral dryness,

which is often (but not always) associated with hypofunction of the salivary glands.[3] The term is derived
from the Greek words (xeros) meaning dry and
(stoma) meaning mouth.[4][5] Hyposalivation is
a clinical diagnosis that is made based on the history and
examination,[1] but reduced salivary ow rates have been
given objective denitions. Salivary gland hypofunction
has been dened as any objectively demonstrable reduction in whole and/or individual gland ow rates.[6] An unstimulated whole saliva ow rate in a normal person is
0.30.4 ml per minute,[7] and below 0.1 ml per minute is
signicantly abnormal. A stimulated saliva ow rate less
than 0.5 ml per gland in 5 minutes or less than 1 ml per
gland in 10 minutes is decreased.[1] The term subjective
xerostomia is sometimes used to describe the symptom
in the absence of any detectable abnormality or cause.[8]
Xerostomia may also result from a change in composition of saliva (from serous to mucous).[6] Salivary gland
dysfunction is an umbrella term for the presence of either xerostomia or salivary gland hypofunction.[6]

Dysgeusia altered taste sensation (e.g., a metallic

taste)[1] and dysosmia, altered sense of smell.[3]
Intraoral halitosis [1] possibly due to increased activity of halitogenic biolm on the posterior dorsal
tongue (although dysgeusia may cause a complaint
of nongenuine halitosis in the absence of hyposalivation).
Oral dysesthesia a burning or tingling sensation in
the mouth.[1][3]
Saliva that appears thick or ropey.[9]
Mucosa that appears dry.[9]
A lack of saliva pooling in the oor of the mouth
during examination.[1]
Dysphagia diculty swallowing and chewing, especially when eating dry foods. Food may stick to
the tissues during eating.[9]
The tongue may stick to the palate,[7] causing a
clicking noise during speech, or the lips may stick
together.[1]

Signs and symptoms

True hyposalivation may give the following signs and

symptoms:

Gloves or a dental mirror may stick to the tissues.[9]

Fissured tongue with atrophy of the liform papillae and a lobulated, erythematous appearance of the
tongue.[1][9]

Dental caries (xerostomia related caries) - Without the anticariogenic actions of saliva, tooth de1

3 DIFFERENTIAL DIAGNOSIS
Saliva cannot be milked (expressed) from the 3.1 Physiologic
parotid duct.[1]
Salivary ow rate is decreased during sleep, which may
Diculty wearing dentures, e.g., when swallowing lead to a transient sensation of dry mouth upon waking.
or speaking.[1] There may be generalized mucosal This disappears with eating or drinking or with oral hysoreness and ulceration of the areas covered by the giene. When associated with halitosis, this is sometimes
denture.[3]
termed morning breath. Dry mouth is also a common
sensation during periods of anxiety, probably owing to
Mouth soreness and oral mucositis.[1][3]
enhanced sympathetic drive.[10] Dehydration is known to
cause hyposalivation,[1] the result of the body trying to
Lipstick or food may stick to the teeth.[1]
conserve uid. Physiologic age-related changes in sali A need to sip drinks frequently while talking or vary gland tissues may lead to a modest reduction in salivary output and partially explain the increased prevalence
eating.[3]
of xerostomia in older people.[1] However, polypharmacy
Dry, sore, and cracked lips and angles of mouth.[3] is thought to be the major cause in this group, with no
signicant decreases in salivary ow rate being likely to
Thirst.[3]
occur through aging alone.[9][11]

However, sometimes the clinical ndings do not correlate with the symptoms experienced.[9] E.g., a person with
signs of hyposalivation may not complain of xerostomia.
Conversely a person who reports experiencing xerostomia may not show signs of reduced salivary secretions
(subjective xerostomia).[8] In the latter scenario, there are
often other oral symptoms suggestive of oral dysesthesia
(burning mouth syndrome).[3] Some symptoms outside
the mouth may occur together with xerostomia. These
include:
Xerophthalmia (dry eyes).[1]
Inability to cry.[1]
Blurred vision.[1]

3.2 Drug induced

Aside from physiologic causes of xerostomia, iatrogenic
eects of medications are the most common cause.[1] A
medication which is known to cause xerostomia may be
termed xerogenic.[3] Over 500 medications produce xerostomia as a side eect (see table).[9] Sixty-three percent of the top 200 most commonly prescribed drugs in
the United States are xerogenic.[9] The likelihood of xerostomia increases in relation to the total number of medications taken, whether the individual medications are xerogenic or not.[9] The sensation of dryness usually starts
shortly after starting the oending medication or after increasing the dose.[1] Anticholinergic, sympathomimetic,
or diuretic drugs are usually responsible.[1]

Photophobia (light intolerance).[1]

Dryness of other mucosae, e.g., nasal, laryngeal, 3.3 Sjgrens syndrome
and/or genital.[1]
Main article: Sjgrens syndrome
Burning sensation.[1]
Xerostomia may be caused by autoimmune damage to
the salivary glands. Sjgrens syndrome is one such disease, and it causes other symptoms, including xeroph Dysphonia (voice changes).[1]
thalmia (dry eyes), dry vagina, fatigue, myalgia (muscle
There may also be other systemic signs and symp- pain), and arthralgia (joint pain). Females are more likely
toms if there is an underlying cause such as Sjgrens to suer from autoimmune disease, and 90% of people
syndrome,[1] for example, joint pain due to associated with Sjgrens syndrome are women. Primary Sjgrens
syndrome is the combination of dry eyes and xerostorheumatoid arthritis.
mia. Secondary Sjgrens syndrome is identical to primary form but with the addition of a combination of other
connective tissue disorders such as systemic lupus erythe3 Dierential diagnosis
matosus or rheumatoid arthritis.[8]
Itching or grittiness.[1]

The dierential of hyposalivation signicantly overlaps

with that of xerostomia. A reduction in saliva production 3.4 Sicca syndrome
to about 50% of the normal unstimulated level will usually result in the sensation of dry mouth.[8] Altered saliva Sicca simply means dryness. Sicca syndrome is not
composition may also be responsible for xerostomia.[8]
a specic condition, and there are varying denitions,

3
but the term can describe oral and eye dryness that is be carried out.[1]
not caused by autoimmune diseases (e.g. Sjogren Syndrome).

5 Treatment
3.5

Other causes

Oral dryness may also be caused by mouth breathing,[3]

usually caused by partial obstruction of the upper
respiratory tract. Water or metabolite loss can lead to
xerostomia. Examples include hemorrhage, vomiting,
diarrhea, and fever.[1][9] Irradiation of the salivary
glands often causes profound hyposalivation.[1] Alcohol may be involved in the etiology as a cause of
salivary gland disease, liver disease, or dehydration.[3]
Smoking is another possible cause.[9] Other recreational
drugs such as methamphetamine,[12] cannabis,[13]
hallucinogens,[14] or heroin,[15] may be implicated.
Rarer causes include Diabetes (dehydration),[1]
hyperparathyroidism,[1] cholinergic dysfunction (either congenital or autoimmune),[1] salivary gland aplasia
or atresia,[3] sarcoidosis,[3] human immunodeciency
virus infection (due to antiretroviral therapy, but also possibly diuse inltrative lymphocytosis syndrome),[1][3][8]
graft-versus-host disease,[3] renal failure,[3] hepatitis C
virus infection,[8] and Lambert-Eaton syndrome.[16]

Diagnostic approach

A diagnosis of hyposalivation is based predominantly on

the clinical signs and symptoms.[1] There is little correlation between symptoms and objective tests of salivary
ow,[17] such as sialometry. This test is simple and noninvasive, and involves measurement of all the saliva a
patient can produce during a certain time, achieved by
dribbling into a container. Sialometery can yield measures of stimulated salivary ow or unstimulated salivary
ow. Stimulated salivary ow rate is calculated using
a stimulant such as 10% citric acid dropped onto the
tongue, and collection of all the saliva that ows from
one of the parotid papillae over ve or ten minutes. Unstimulated whole saliva ow rate more closely correlates
with symptoms of xerostomia than stimulated salivary
ow rate.[1] Sialography involves introduction of radioopaque dye such as iodine into the duct of a salivary
gland.[1] It may show blockage of a duct due to a calculus. Salivary scintiscanning using technetium is rarely
used. Other medical imaging that may be involved in the
investigation include chest x-ray (to exclude sarcoidosis),
ultrasonography and magnetic resonance imaging (to exclude Sjgrens syndrome or neoplasia).[1] A minor salivary gland biopsy, usually taken from the lip,[18] may be
carried out if there is a suspicion of organic disease of
the salivary glands.[1] Blood tests and urinalysis may be
involved to exclude a number of possible causes.[1] To
investigate xerophthalmia, the Schirmer test of lacrimal
ow may be indicated.[1] Slit-lamp examination may also

The successful treatment of xerostomia is dicult to

achieve and often unsatisfactory.[9] This involves nding
any correctable cause and removing it if possible, but
in many cases it is not possible to correct the xerostomia itself, and treatment is symptomatic, and also focuses on preventing tooth decay through improving oral
hygiene. Where the symptom is caused by hyposalivation secondary to underlying chronic disease, xerostomia
can be considered permanent or even progressive.[8] The
management of salivary gland dysfunction may involve
the use of saliva substitutes and/or saliva stimulants:[6]
Mouthwashes, pastes, mints, gels, and gums have attempted to adequately address the condition with limited results. Salivary enzymes and glycerine work well
for a portion of suerers but require frequent application. Lozenges to treat the eects of xerostomia show
sustained results with fewer doses needed. Most contain
xylitol to address decay and demineralization and a few
add essential oils to promote a healthier oral cavity while
combating dry mouth[19]
Saliva substitutes these include water, articial salivas (mucin-based, carboxymethylcellulosebased), and other substances (milk, vegetable oil).
Saliva stimulants organic acids (ascorbic acid,
malic acid), chewing gum, parasympathomimetic
drugs (choline esters, e.g. pilocarpine hydrochloride, cholinesterase inhibitors), and other substances
(sugar-free mints, nicotinamide).
Saliva substitutes can improve xerostomia, but tend not
to improve the other problems associated with salivary
gland dysfunction.[6] Saliva stimulants may improve xerostomia symptoms and other problems associated with
salivary gland dysfunction, and patients nd them more
eective than saliva substitutes.[6] Salivary stimulants are
probably only useful in people with some remaining detectable salivary function.[3] A drug or substance that increases the rate of salivary ow is termed a sialogogue.
A systematic review of the treatment of dry mouth found
no strong evidence to suggest that a specic topical therapy is eective.[8] The review reported limited evidence
that oxygenated glycerol triester spray was more eective than electrolyte sprays.[8] Sugar free chewing gum increases saliva production but there is no strong evidence
that it improves symptoms.[8] There is a suggestion that
intraoral devices and integrated mouthcare systems may
be eective in reducing symptoms, but there was a lack
of strong evidence.[8] A systematic review of the management of radiotherapy induced xerostomia with parasympathomimetic drugs found that there was limited evidence to support the use of pilocarpine in the treatment

of radiation-induced salivary gland dysfunction.[6] It was

suggested that, barring any contraindications, a trial of
the drug be oered in the above group (at a dose of ve
mg three times per day to minimize side eects).[6] Improvements can take up to twelve weeks.[6] However, pilocarpine is not always successful in improving xerostomia symptoms.[6] The review also concluded that there
was little evidence to support the use of other parasympathomimetics in this group.[6]

Epidemiology

REFERENCES

[7] Coulthard [et al.], Paul (2008). Oral and Maxillofacial

Surgery, Radiology, Pathology and Oral Medicine (2nd
ed.). Edinburgh: Churchill Livingstone/Elsevier. pp.
210, 212213. ISBN 9780443068966.
[8] Furness, S; Worthington, HV; Bryan, G; Birchenough,
S; McMillan, R (Dec 7, 2011).
Furness, Susan,
ed.
Interventions for the management of dry
mouth:
topical therapies.
Cochrane database
of systematic reviews (Online) (12):
CD008934.
doi:10.1002/14651858.CD008934.pub2.
PMID
22161442.
[9] Bouquot, Brad W. Neville , Douglas D. Damm, Carl M.
Allen, Jerry E. (2002). Oral & maxillofacial pathology (2.
ed.). Philadelphia: W.B. Saunders. pp. 398399. ISBN
0721690033.

Xerostomia is a very common symptom. A conservative

estimate of prevalence is about 20% in the general population, with increased prevalences in females (up to 30%)
[10] Boyce, HW; Bakheet, MR (February 2005). Sialorrhea:
and the elderly (up to 50%).[8]

History

Xerostomia has been used as a test to detect lies, which

relied on emotional inhibition of salivary secretions to indicate possible incrimination.[20]

See also
Xerosis (dry skin)

References

[1] Scully, Crispian (2008). Oral and maxillofacial medicine

: the basis of diagnosis and treatment (2nd ed.). Edinburgh: Churchill Livingstone. pp. 17, 31, 41, 7985.
ISBN 9780443068188.
[2] Wijers OB, Levendag PC, Braaksma MM, Boonzaaijer
M, Visch LL, Schmitz PI (2002), Patients with head and
neck cancer cured by radiation therapy: a survey of the dry
mouth syndrome in long-term survivors, Head Neck 24
(8): 737747, doi:10.1002/hed.10129, PMID 12203798.
[3] Tyldesley, Anne Field, Lesley Longman in collaboration
with William R. (2003). Tyldesleys Oral medicine (5th
ed.). Oxford: Oxford University Press. pp. 19, 9093.
ISBN 0192631470.
[4] Etymology of xeros at Online Etymology Dictionary.
Douglas Harper. Retrieved 9 February 2013.
[5] Etymology of stoma at Online Etymology Dictionary.
Douglas Harper. Retrieved 9 February 2013.
[6] Davies, AN; Shorthose, K (Jul 18, 2007). Davies, Andrew N, ed. Parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy.
Cochrane database of systematic reviews (Online) (3):
doi:10.1002/14651858.CD003782.pub2.
CD003782.
PMID 17636736.

a review of a vexing, often unrecognized sign of oropharyngeal and esophageal disease. Journal of Clinical Gastroenterology 39 (2): 8997. PMID 15681902.

[11] Turner MD, Ship JA (September 2007). Dry mouth and

its eects on the oral health of elderly people. Journal of the American Dental Association (1939) 138 (1):
15S20S. doi:10.14219/jada.archive.2007.0358. PMID
17761841.
[12] Saini, T; Edwards, PC; Kimmes, NS; Carroll, LR; Shaner,
JW; Dowd, FJ (2005). Etiology of xerostomia and dental
caries among methamphetamine abusers. Oral health &
preventive dentistry 3 (3): 18995. PMID 16355653.
[13] Versteeg, PA; Slot, DE; van der Velden, U; van der Weijden, GA (Nov 2008). Eect of cannabis usage on
the oral environment: a review. International journal
of dental hygiene 6 (4): 31520. doi:10.1111/j.16015037.2008.00301.x. PMID 19138182.
[14] Fazzi, M; Vescovi, P; Savi, A; Manfredi, M; Peracchia,
M (October 1999). "[The eects of drugs on the oral
cavity]". Minerva stomatologica 48 (10): 48592. PMID
10726452.
[15] DrugFacts: Heroin on National Institute of Drug Abuse.
National Institutes of Health. Retrieved 9 February 2013.
[16] Newsom-Davis, J (February 2004). Lambert-Eaton
myasthenic syndrome. Revue neurologique 160 (2):
17780. doi:10.1016/S0035-3787(04)70888-7. PMID
15034474.
[17] Visvanathan, V; Nix, P (February 2010).
Managing the patient presenting with xerostomia: a review. International journal of clinical practice 64 (3):
4047. doi:10.1111/j.1742-1241.2009.02132.x. PMID
19817913.
[18] Fox, PC; van der Ven, PF; Sonies, BC; Weienbach,
JM; Baum, BJ (April 1985). Xerostomia: evaluation
of a symptom with increasing signicance. Journal of
the American Dental Association (1939) 110 (4): 51925.
PMID 3858368.
[19] Changes in Dental Practice over 20 years.>

[20] Iorgulescu, G (JulSep 2009). Saliva between normal

and pathological. Important factors in determining systemic and oral health. Journal of medicine and life 2 (3):
3037. PMID 20112475.

10

External links

University of Illinois at Chicago

NIH
MedlinePlus Encyclopedia
Drymouth Drymouth Drug Database

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