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 flow (hyposalivation), or have no identifiable cause.
This symptom is very common and is often seen as a side effect 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 identifiable cause, and
there may be a psychogenic reason for the complaint.[1]

Contents

1 Definition
2 Signs and symptoms
3 Differential diagnosis
o 3.1 Physiologic
o 3.2 Drug induced
o 3.3 Sjgren's syndrome
o 3.4 Sicca syndrome
o 3.5 Other causes
4 Diagnostic approach
5 Treatment
6 Epidemiology
7 History
8 See also
9 References
10 External links

Definition
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 flow rates
have been given objective definitions. Salivary gland hypofunction has been defined as any
objectively demonstrable reduction in whole and/or individual gland flow rates.[6] An
unstimulated whole saliva flow rate in a normal person is 0.30.4 ml per minute,[7] and below 0.1
ml per minute is significantly abnormal. A stimulated saliva flow 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]

Signs and symptoms

True hyposalivation may give the following signs and symptoms:

Dental caries (xerostomia related caries) - Without the anticariogenic actions of saliva,
tooth decay is a common feature and may progress much more aggressively than it would
otherwise ("rampant caries"). It may affect 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]
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 flow of saliva.[7] There may
swollen salivary glands even without acute infection, possibly caused by autoimmune
involvement.[3]
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 biofilm 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 floor of the mouth during examination.[1]
Dysphagia difficulty 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]
Gloves or a dental mirror may stick to the tissues.[9]
Fissured tongue with atrophy of the filiform papillae and a lobulated, erythematous
appearance of the tongue.[1][9]
Saliva may not be "milked" (expressed) from the parotid duct.[1]
Difficulty wearing dentures, e.g., when swallowing or speaking.[1] There may be
generalized mucosal soreness and ulceration of the areas covered by the denture.[3]
Mouth soreness and oral mucositis.[1][3]
Lipstick or food may stick to the teeth.[1]
A need to sip drinks frequently while talking or eating.[3]
Dry, sore, and cracked lips and angles of mouth.[3]
Thirst.[3]

However, sometimes the clinical findings 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]
Photophobia (light intolerance).[1]
Dryness of other mucosae, e.g., nasal, laryngeal, and/or genital.[1]
Burning sensation.[1]
Itching or grittiness.[1]
Dysphonia (voice changes).[1]

There may also be other systemic signs and symptoms if there is an underlying cause such as
Sjgren's syndrome,[1] for example, joint pain due to associated rheumatoid arthritis.

Differential diagnosis
The differential of hyposalivation significantly overlaps with that of xerostomia. A reduction in
saliva production to about 50% of the normal unstimulated level will usually result in the
sensation of dry mouth.[8] Altered saliva composition may also be responsible for xerostomia.[8]

Physiologic
Salivary flow rate is decreased during sleep, which may lead to a transient sensation of dry
mouth upon waking. This disappears with eating or drinking or with oral hygiene. When
associated with halitosis, this is sometimes termed "morning breath". Dry mouth is also a
common sensation during periods of anxiety, probably owing to enhanced sympathetic drive.[10]
Dehydration is known to cause hyposalivation,[1] the result of the body trying to conserve fluid.
Physiologic age-related changes in salivary gland tissues may lead to a modest reduction in
salivary output and partially explain the increased prevalence of xerostomia in older people.[1]
However, polypharmacy is thought to be the major cause in this group, with no significant
decreases in salivary flow rate being likely to occur through aging alone.[9][11]

Drug induced
Medications associated with
xerostomia (with or without objective
hyposalivation and/or altered saliva
consistency).[1]

Atropine, atropinics and

hyoscine
Antidepressants (tricyclic
antidepressants, selective
serotonin reuptake inhibitors,
lithium)
Antihypertensives (e.g.

terazosin, prazosin, clonidine,

atenolol, propranolol)
Phenothiazines
Antihistamines
Anti reflux drugs (proton pump
inhibitors, e.g. omeprazole)
Opioids
Cannabinoids
Cytotoxic drugs
Retinoids
Bupropion
Protease inhibitors
Didanosine
Diuretics
Ephedrine
Benzodiazepines
Interleukin-2

Aside from physiologic causes of xerostomia, iatrogenic effects 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 effect (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 offending medication or after increasing the dose.[1] Anticholinergic,
sympathomimetic, or diuretic drugs are usually responsible.[1]

Sjgren's syndrome
Main article: Sjgren's syndrome
Xerostomia may be caused by autoimmune damage to the salivary glands. Sjgren's syndrome is
one such disease, and it causes other symptoms, including xerophthalmia (dry eyes), dry vagina,
fatigue, myalgia (muscle pain), and arthralgia (joint pain). Females are more likely to suffer from
autoimmune disease, and 90% of people with Sjgren's syndrome are women. Primary Sjgren's
syndrome is the combination of dry eyes and xerostomia. Secondary Sjgren's syndrome is
identical to primary form but with the addition of a combination of other connective tissue
disorders such as systemic lupus erythematosus or rheumatoid arthritis.[8]

Sicca syndrome
"Sicca" simply means dryness. Sicca syndrome is not a specific condition, and there are varying
definitions, but the term can describe oral and eye dryness that is not caused by autoimmune
diseases (e.g. Sjogren Syndrome).

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 immunodeficiency virus infection (due to antiretroviral therapy, but also
possibly diffuse infiltrative 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 flow,[17] such as
sialometry. This test is simple and non invasive, 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 flow or unstimulated salivary flow. Stimulated salivary
flow rate is calculated using a stimulant such as 10% citric acid dropped onto the tongue, and
collection of all the saliva that flows from one of the parotid papillae over five or ten minutes.
Unstimulated whole saliva flow rate more closely correlates with symptoms of xerostomia than
stimulated salivary flow rate.[1] Sialography involves introduction of radio-opaque 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 Sjgren's 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 flow may be
indicated.[1] Slit-lamp examination may also be carried out.[1]

Treatment
The successful treatment of xerostomia is difficult to achieve and often unsatisfactory.[9] This
involves finding 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 sufferers but
require frequent application. Lozenges to treat the effects 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, artificial salivas (mucin-based,

carboxymethylcellulose-based), 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 find them more effective
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
flow is termed a sialogogue. A systematic review of the treatment of dry mouth found no strong
evidence to suggest that a specific topical therapy is effective.[8] The review reported limited
evidence that oxygenated glycerol triester spray was more effective 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 effective 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 offered in the above group (at a dose of
five mg three times per day to minimize side effects).[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]