Xerostomia is dry mouth caused by reduced or absent flow of saliva.
This condition can result in discomfort, interfere with speech and swallowing, make wearing dentures difficult, cause halitosis, and impair oral hygiene by causing a decrease in oral pH and an increase in bacterial growth. Long-standing xerostomia can result in severe tooth decay and oral candidiasis. Xerostomia is a common complaint among older adults, affecting about 20% of them.
(See also Introduction to the Approach to the Dental Patient.)
Pathophysiology of Xerostomia
Stimulation of the oral mucosa signals the salivatory nuclei in the medulla, triggering an efferent response. The efferent nerve impulses release acetylcholine at salivary gland nerve terminals, activating muscarinic receptors (M3), which increase saliva production and flow. Medullary signals responsible for salivation may also be modulated by cortical inputs from other stimuli (eg, taste, smell, anxiety).
Etiology of Xerostomia
Xerostomia is usually caused by the following:
Drugs
Radiation to the head and neck (for cancer treatment)
Systemic disorders are less commonly the cause, but xerostomia is common in Sjögren syndrome and may occur in HIV/AIDS, uncontrolled diabetes, and certain other disorders.
Drugs
Drugs are the most common cause (see table Some Causes of Xerostomia); about 400 prescription medications and many over-the-counter (OTC) medications cause decreased salivation. The most common include the following:
Anticholinergics
Antineoplastics (chemotherapeutic agents)
Some Causes of Xerostomia
Cause | Examples |
|---|---|
Drugs | |
Anticholinergic | Antidepressants Antiemetics Antihistamines Antipsychotics Antispasmodics Anxiolytics |
Recreational/illicit | Cannabis Methamphetamines Tobacco |
Other | Antihypertensives Antineoplastics (chemotherapeutic agents) Antiparkinsonian medications Bronchodilators Decongestants Diuretics Meperidine, methadone, and other opioidsMeperidine, methadone, and other opioids |
Systemic disorders | |
― | Amyloidosis Diabetes HIV infection Leprosy Sarcoidosis Sjögren syndrome Tuberculosis |
Other | |
― | Excessive mouth breathing Head and neck trauma Radiation treatment Viral infections |
Chemotherapeutic agents cause severe dryness and stomatitis while they are being taken; these problems usually end after therapy is stopped.
Other common drug classes that cause xerostomia include antihypertensives, anxiolytics, and antidepressants (less severe with selective serotonin reuptake inhibitors [SSRIs] than with tricyclics).
The rise of illicit methamphetaminemethamphetamine use has resulted in an increasing incidence of meth mouth, which is severe tooth decay and periodontal inflammation caused by methamphetamine-induced xerostomia. The damage is exacerbated by the caused by methamphetamine-induced xerostomia. The damage is exacerbated by thebruxing 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 usually causes a decrease of saliva.
Radiation
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).
Evaluation of Xerostomia
History
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 psychological 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 and illicit drugs should be taken.
Review of systems should seek symptoms of causative disorders, including dry eyes, dry skin, rashes, and joint pain (Sjögren syndrome).
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. Drug profiles should be reviewed for potential offending medications (see table Some Causes of Xerostomia).
Physical examination
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. 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 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.
Red flags
The following findings are of particular concern:
Extensive tooth decay
Concomitant dry eyes, dry skin, rash, or joint pain
Risk factors for HIV
Interpretation of findings
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 medication and stops after cessation of that medication 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. Severe tooth discoloration and decay, out of proportion to expected findings, may be indicative of illicit drug use, particularly methamphetamines. Xerostomia that occurs only during nighttime or that is noted only on awakening may be indicative of excessive mouth breathing in a dry environment.
Testing
Sialometry
Salivary gland biopsy
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, sarcoidosis, amyloidosis, tuberculosis, or cancer) and HIV testing. The lower lip is a convenient site for biopsy.
Treatment of Xerostomia
Cause treated and causative medications or recreational/illicit drugs stopped when possible
Cholinergic medications
Saliva substitutes
Regular oral hygiene and dental care to prevent tooth decay
When possible, the cause of xerostomia should be addressed and treated.
For patients with drug-related xerostomia whose therapy cannot be changed to another drug, drug schedules should be modified to achieve maximum drug effect during the day because nighttime xerostomia is more likely to cause caries. Custom-fitted acrylic night guards carrying fluoride gel may also help limit caries in these patients. For all medications, easy-to-take formulations, such as liquids, should be considered, and sublingual dosage forms should be avoided. The mouth and throat should be lubricated with water before swallowing capsules and tablets or before using sublingual nitroglycerin. Patients should avoid decongestants and antihistamines.For patients with drug-related xerostomia whose therapy cannot be changed to another drug, drug schedules should be modified to achieve maximum drug effect during the day because nighttime xerostomia is more likely to cause caries. Custom-fitted acrylic night guards carrying fluoride gel may also help limit caries in these patients. For all medications, easy-to-take formulations, such as liquids, should be considered, and sublingual dosage forms should be avoided. The mouth and throat should be lubricated with water before swallowing capsules and tablets or before using sublingual nitroglycerin. Patients should avoid decongestants and antihistamines.
Patients using continuous positive airway pressure for obstructive sleep apnea may benefit from using the humidifier function of the device. Patients using oral appliance therapy may benefit from a room humidifier.
Symptom control
Symptomatic treatment consists of measures that do the following:
Increase existing saliva
Replace lost secretions
Control caries
Medications that augment saliva production include cevimeline and pilocarpine, both cholinergic agonists. Cevimeline (30 mg orally 3 times a day) has less MMedications 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.(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 patients who breathe mainly through their mouth, who typically have their worst symptoms at night.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 patients who breathe mainly through their mouth, 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 (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 (1).
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.
Treatment reference
1. Chan AKY, Tamrakar M, Jiang CM, et al: Clinical evidence for professionally applied fluoride therapy to prevent and arrest dental caries in older adults: A systematic review. J Dent 125:104273. doi: 10.1016/j.jdent.2022.104273
Geriatrics Essentials: Xerostomia
Although xerostomia becomes more common among older patients, this is probably due to the many medications typically used by those patients rather than aging itself.
Key Points
Medications are the most common cause, but systemic diseases (most commonly Sjögren syndrome or HIV) and radiation therapy also can cause xerostomia.
Symptomatic treatment includes increasing existing saliva flow with stimulants or medications, and artificial saliva replacement; xylitol-containing gum and sugarless candy may be useful.
Patients with xerostomia are at high risk of tooth decay; meticulous oral hygiene, additional preventive measures in home care, and professionally applied fluorides are essential.
