Xerostomia

Drugs are the most common cause (see table Some Causes of Xerostomia Some Causes of Xerostomia ); about 400 prescription drugs and many over-the-counter (OTC) drugs cause decreased salivation. The most common include the following:

Chemotherapy drugs Systemic Cancer Therapy Systemic cancer therapy includes chemotherapy (ie, conventional or cytotoxic chemotherapy), hormone therapy, targeted therapy, and immune therapy (see also Overview of Cancer Therapy). The number... read more cause severe dryness and stomatitis Stomatitis Oral inflammation and ulcers, known as stomatitis, may be mild and localized or severe and widespread. They are invariably painful. (See also Evaluation of the Dental Patient and Gingivitis... read more while they are being taken; these problems usually end after therapy is stopped.

Other common drug classes that cause xerostomia include antihypertensives Drugs for Hypertension A number of drug classes are effective for initial and subsequent management of hypertension: Adrenergic modifiers Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers... read more , anxiolytics Sedatives Sedatives include benzodiazepines, barbiturates, and related drugs. High doses can cause decreased level of consciousness and respiratory depression, which may require intubation and mechanical... read more , and antidepressants Drug Treatment of Depression Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (less severe with selective serotonin reuptake inhibitors [SSRIs] than with tricyclics).

The rise of illicit methamphetamine Amphetamines Amphetamines are sympathomimetic drugs with central nervous system stimulant and euphoriant properties whose toxic adverse effects include delirium, hypertension, seizures, and hyperthermia... read more use has resulted in an increasing incidence of meth mouth, which is severe tooth decay and periodontal inflammation Periodontitis Periodontitis is a chronic inflammatory oral disease that progressively destroys the tooth-supporting apparatus. It usually manifests as a worsening of gingivitis and then, if untreated, with... read more caused by methamphetamine-induced xerostomia. The damage is exacerbated by the bruxing Bruxism Bruxism is clenching or grinding of teeth. Bruxism can occur during sleep (sleep bruxism) and while awake (awake bruxism). In some people, bruxism causes headaches, neck pain, and/or jaw pain... read more and clenching caused by the drug along with elevated intake of sugary beverages and poor oral hygiene while under the influence of the drug. This combination causes very rapid destruction of teeth.

Tobacco use Tobacco Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more usually causes a decrease of saliva.

Incidental radiation to the salivary glands during radiation therapy for head and neck cancer often causes severe xerostomia (5200 cGy causes severe, permanent dryness, but even low doses can cause temporary drying).

History of present illness should include acuity of onset, temporal patterns (eg, constant vs intermittent, presence only on awakening), provoking factors, including situational or psychogenic factors (eg, whether xerostomia occurs only during periods of psychologic stress or certain activities), assessment of fluid status (eg, fluid intake habits, recurrent vomiting or diarrhea), and sleeping habits. A history of use of recreational drugs should be taken.

Review of systems should seek symptoms of causative disorders, including dry eyes, dry skin, rashes, and joint pain (Sjögren syndrome Sjögren Syndrome Sjögren syndrome is a relatively common chronic, autoimmune, systemic, inflammatory disorder of unknown cause. It is characterized by dryness of the mouth, eyes, and other mucous membranes ... read more ).

Past medical history should inquire about conditions associated with xerostomia, including Sjögren syndrome, history of radiation treatment, head and neck trauma, and a diagnosis of or risk factors for HIV infection Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more . Drug profiles should be reviewed for potential offending drugs (see table Some Causes of Xerostomia Some Causes of Xerostomia ).

Physical examination is focused on the oral cavity, specifically any apparent dryness (eg, whether the mucosa is dry, sticky, or moist; whether saliva is foamy, thick, stringy, or normal in appearance), the presence of any lesions caused by Candida albicans, and the condition of the teeth.

The presence and severity of xerostomia can be assessed in several ways. For example, a tongue blade can be held against the buccal mucosa for 10 seconds. If the tongue blade falls off immediately when released, salivary flow is considered normal. The more difficulty encountered removing the tongue blade, the more severe the xerostomia. In women, the lipstick sign, where lipstick adheres to the front teeth, may be a useful indicator of xerostomia.

If there appears to be dryness, the submandibular, sublingual, and parotid glands should be palpated while observing the ductal openings for saliva flow. The openings are at the base of the tongue anteriorly for the submandibular and sublingual glands and on the middle of the inside of the cheek for the parotid glands. Drying the duct openings with a gauze square before palpation aids observation. If a graduated container is available, the patient can expectorate once to empty the mouth and then expectorate all saliva into the container. Normal production is 0.3 to 0.4 mL/min. Significant xerostomia is 0.1 mL/min.

Dental caries Caries Caries is tooth decay, commonly called cavities. The symptoms—tender, painful teeth—appear late. Diagnosis is based on inspection, probing of the enamel surface with a fine metal instrument... read more may be observed at the margins of restorations or in unusual places (eg, at the gum line, incisal edges, or cusp tips of the teeth).

A common manifestation of C. albicans infection is areas of erythema and atrophy (eg, loss of papillae on the dorsum of the tongue). Less common is the better-known white, cheesy curd that bleeds when wiped off.

The following findings are of particular concern:

Xerostomia is diagnosed by symptoms, appearance, and absence of salivary flow when massaging the salivary glands.

No further assessment is required when xerostomia occurs after initiation of a new drug and stops after cessation of that drug or when symptoms appear within several weeks of irradiation of the head and neck. Xerostomia that occurs with abrupt onset after head and neck trauma may be caused by nerve damage.

Concomitant presence of dry eyes, dry skin, rash, or joint pain, particularly in a female patient, suggests a diagnosis of Sjögren syndrome Sjögren Syndrome Sjögren syndrome is a relatively common chronic, autoimmune, systemic, inflammatory disorder of unknown cause. It is characterized by dryness of the mouth, eyes, and other mucous membranes ... read more . Severe tooth discoloration and decay, out of proportion to expected findings, may be indicative of illicit drug use, particularly methamphetamines Amphetamines Amphetamines are sympathomimetic drugs with central nervous system stimulant and euphoriant properties whose toxic adverse effects include delirium, hypertension, seizures, and hyperthermia... read more . Xerostomia that occurs only during nighttime or that is noted only on awakening may be indicative of excessive mouth breathing in a dry environment.

For patients in whom the presence of xerostomia is unclear, sialometry can be conducted by placing collection devices over the major duct orifices and then stimulating salivary production with citric acid or by chewing paraffin. Normal parotid flow is 0.4 to 1.5 mL/min/gland. Flow monitoring can also help determine response to therapy.

The cause of xerostomia is often apparent, but if the etiology is unclear and systemic disease is considered possible, further assessment should be pursued with biopsy of a minor salivary gland (for detection of Sjögren syndrome Sjögren Syndrome Sjögren syndrome is a relatively common chronic, autoimmune, systemic, inflammatory disorder of unknown cause. It is characterized by dryness of the mouth, eyes, and other mucous membranes ... read more , sarcoidosis Sarcoidosis Sarcoidosis is an inflammatory disorder resulting in noncaseating granulomas in one or more organs and tissues; etiology is unknown. The lungs and lymphatic system are most often affected, but... read more , amyloidosis Amyloidosis Amyloidosis is any of a group of disparate conditions characterized by extracellular deposition of insoluble fibrils composed of misaggregated proteins. These proteins may accumulate locally... read more , tuberculosis Tuberculosis (TB) Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent period following initial infection. Tuberculosis most commonly affects the lungs. Symptoms include... read more , or cancer Overview of Cancer Cancer is an unregulated proliferation of cells. Its prominent properties are A lack of cell differentiation Local invasion of adjoining tissue Metastasis, which is spread to distant sites through... read more ) and HIV testing Diagnostic tests Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more . The lower lip is a convenient site for biopsy.

Symptomatic treatment consists of measures that do the following:

Drugs that augment saliva production include cevimeline and pilocarpine, both cholinergic agonists. Cevimeline (30 mg orally 3 times a day) has less M₂ (cardiac) receptor activity than pilocarpine and a longer half-life. The main adverse effect is nausea. Pilocarpine (5 mg orally 3 times a day) may be given after ophthalmologic and cardiorespiratory contraindications are excluded; adverse effects include sweating, flushing, and polyuria.

Sipping sugarless fluids frequently, chewing xylitol-containing gum, and using an over-the-counter saliva substitute containing carboxymethylcellulose, hydroxyethylcellulose, or glycerin may help. Petroleum jelly can be applied to the lips and under dentures to relieve drying, cracking, soreness, and mucosal trauma. A cold-air humidifier may aid mouth breathers, who typically have their worst symptoms at night.

Meticulous oral hygiene is essential. Patients should brush and floss regularly (including just before bedtime) and use fluoride rinses or gels daily; using newer toothpastes with added calcium and phosphates also may help avoid rampant caries. An increased frequency of preventive dental visits with plaque removal is advised. The most effective way to prevent caries is to sleep with individually fitted carriers containing 1.1% sodium fluoride or 0.4% stannous fluoride. In addition, a dentist can apply a 5% sodium fluoride varnish 2 to 4 times a year.

Patients should avoid sugary or acidic foods and beverages and any irritating foods that are dry, spicy, astringent, or excessively hot or cold. It is particularly important to avoid ingesting sugar near bedtime.