Journal of Investigative and Clinical Dentistry (2014), 5, 1–8

REVIEW ARTICLE
Oral Medicine

Xerostomia in geriatric patients: a burgeoning global

concern
Sukumaran Anil1, Sajith Vellappally2, Mohamed Hashem2, Reghunathan S. Preethanath1,
Shankargouda Patil3 & Lakshman P. Samaranayake2,4
1 Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
2 Department of Dental Health, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
3 Department of Oral Pathology and Microbiology, Faculty of Dental Sciences, M.S. Ramaiah University of Applied Sciences, Bangalore,
Karnataka, India
4 School of Dentistry, University of Queensland, Brisbane, Qld, Australia

Keywords
aging, artificial saliva, dry mouth,
hyposalivation, xerostomia.
Correspondence
Professor Lakshman P. Samaranayake, Room
216, Clinical Building, School of Dentistry,
University of Queensland, 200 Turbot Street,
Brisbane, Queensland 4000, Australia.
Tel: +61-7 3365 8062
Email: l.samaranayake@uq.edu.au
Received 18 May 2014; accepted 12 June
2014.
Abstract
Saliva plays a key role in maintaining oral homeostasis, function, and health.
The prevalence of xerostomia and its consequences are rising due to the
increasing aging population, the effects of some systemic diseases, medical
management, and commonly-prescribed medications that reduce saliva produc-
tion. When salivary function is diminished, patients are at a greater risk of
developing caries, discomfort in wearing dentures, and opportunistic diseases,
such as candidiasis. The psychosocial aspects of xerostomia can range from a
mild effect on self-rated oral health to frustration, embarrassment, unhappiness,
or substantial disruptions in quality of life. This article reviews the clinical
features, diagnosis, and prevalence of dry mouth, as well as its treatment
strategies.

doi: 10.1111/jicd.12120

tributing 50% of the salivary volume. The mucinous

Introduction
Saliva plays an important role in maintaining the physio-
logical homeostasis of the oral cavity. In addition to
humidifying the oral tissues, its lubricating properties aid
in swallowing and talking, and also prevent damage due
to mechanical agents. Saliva contains a variety of electro-
lytes, peptides, glycoproteins, enzymes, immunoglobulin
A, amines, and leucocytes; the buffering effect of saliva, in
particular, has a major effect in preventing tooth demin-
eralization.
The total salivary flow rate in health is approximately
0.3 mL/min at rest, and increases to ≥3 mL/min when
salivation is stimulated. In a healthy individual, the total
daily salivary production is estimated to be 500–
600 mL.1,2 The submandibular glands normally contribute
65% of the total volume of unstimulated saliva, whereas
the parotid glands contribute 20% at rest, but become the
dominant gland for saliva secretion during eating, con-
glycoproteins produced by the submandibular glands,
sublingual glands, and minor salivary glands are impor-
tant in keeping the mucosa moist at all times.3
Xerostomia, the subjective feeling of dry mouth, is a
symptom most frequently associated with alterations in
the quality and quantity of saliva resulting from poor
health, certain drugs, and radiation therapy.4 Several sys-
temic disorders, such as rheumatoid arthritis (RA),
uncontrolled HIV disease, Sj€ ogren’s syndrome, and diabe-
tes mellitus, can cause xerostomia.5–8 The latter is indeed
one of the most adverse side-effects seen in patients sub-
jected to radiation therapy for malignancies in the head
and neck region.9,10 Xerostomia can also be related to
depression, stress, and anxiety in some individuals.11
Symptomatically, chronic xerostomia leads to a persis-
tent dry or burning sensation of the mouth (dry mouth),
eating difficulties, diminished taste acuity (dysgeusia), dis-
comfort during speaking, mucosal infections, denture

ª 2014 Wiley Publishing Asia Pty Ltd 1

Xerostomia in geriatric patients
intolerance, and even bacterial sialadenitis. Xerostomia is
a relatively common complaint, particularly among older
people, and can lead to major consequences with regard
to the quality of their general and oral health and well-
being. The changes in the oral microbiome due to xeros-
tomic states are well recognized as poor salivary flow and
stagnation, leading to the development of acidogenic
microflora, and in particular, various Candida species.12
Prevalence of xerostomia
The prevalence of xerostomia has been reported to be
24–27% in women and 18–21% in men in a European
population,13,14 although data from other regions of the
world are scarce. In Swedish institutionalized older peo-
ple, the prevalence has been reported to be 20–72%. A
prevalence of >55% was observed in older people suffer-
ing from systemic diseases, including diabetes, Parkinson’s
disease, and cancer.15 Epidemiological studies have
shown that the prevalence of xerostomia and salivary
gland hypofunction (SGH) increases with age, and is
strongly associated with medications and health.
The prevalence is almost 100% in patients with
Sj€
ogren’s syndrome and those undergoing radiation ther-
apy for head and neck cancer.16 Xerostomia is also preva-
lent in young patients taking antidepressants, with a 22
times higher risk than normal subjects.17 Thus, it can be
concluded that the condition is a side-effect of various
diseases and the medications used to treat these diseases.
Etiology
Xerostomia has a variety of possible etiological factors.
These are: (a) salivary gland agenesis; (b) injury to the
salivary glands; (c) radiotherapy (RT) of the head and
neck; (d) autoimmune diseases (i.e. Sj€ ogren’s syndrome,
systemic lupus erythematosus, rheumatoid arthritis,
scleroderma, graft-versus-host disease); (e) viral infections
(i.e. paramyxovirus, cytomegalovirus, HIV, hepatotropic
viruses); (f) sialolithiasis; (g) diabetes mellitus; (h) aging;
(i) bacterial infections (i.e. Staphylococcus aureus, Strepto-
coccus pyogens, Escherichia coli); (j) mechanical peripheral
nerve injuries; (k) autonomic system dysfunctions (e.g.
neuropathy of the trigeminal ganglion); (l) oral sensory
impairment, disorders causing difficulties in chewing and
swallowing (e.g. glossopharyngeal nerve palsy); (m) psy-
chogenic factors or mental illness (e.g. anorexia, depres-
sion, schizophrenia); (n) side-effect of medications (e.g.
tricyclic antidepressants, antihypertensive medications,
antispasmodic drugs); (o) mouth breathing; (p) dehydra-
tion; (q) decreased fluid intake; (r) loss of water through
the skin (i.e. fever, excessive sweating); (s) loss of water
through the alimentary tract (i.e. vomiting, diarrhea);
2 ª 2014 Wiley Publishing Asia Pty Ltd
S. Anil et al.
(t) excessive diuresis (i.e. diabetes mellitus, diabetes
insipidus and nephrogenic diabetes, diuretics, renal fail-
ure, loss of urine concentration ability); (u) nutritional
deficiencies and/or eating disorders (i.e. anorexia/buli-
mia); and (v) unknown factors (idiopathic xerostomia).
Xerostomia is generally classified as having primary and
secondary causes. Primary causes comprise conditions
that directly affect the salivary glands and induce xerosto-
mia.18 Sj€ ogren’s syndrome and salivary gland pathology
almost always lead to xerostomia, while other conditions,
such as diabetes mellitus, thyroid disease, adrenal pathol-
ogy, renal or hepatic diseases, hepatitis C virus infection,
and HIV disease, can also cause xerostomia.
Sj€
ogren’s syndrome, the most common autoimmune
disease, is characterized by inflammation of the exocrine
glands and can occur in association with other autoim-
mune diseases, such as RA, systemic sclerosis, or systemic
lupus erythematosus. Sj€ ogren’s syndrome is more preva-
lent in older adults and more common in postmeno-
pausal women.7
Secondary causes of xerostomia include the side-effects
of radiation therapy or chemotherapy and commonly-
prescribed drugs (>500 medications reportedly cause
dry mouth). Medications that interfere with the produc-
tion of saliva and the effect of the upstream or down-
stream metabolic pathways responsible for salivary
secretions cause reduced salivary flow. The most common
medications causing hyposalivation are those with anti-
cholinergic activity, sympathomimetics, and benzodiaze-
pines. Medications that can cause xerostomia include: (a)
those that directly damage salivary glands, such as cyto-
toxic drugs; (b) anticholinergic agents (i.e. atropine,
atropinics, hyoscine) and antireflux agents (i.e. proton-
pump inhibitors e.g. omeprazole); (c) central-acting psy-
choactive agents, such as antidepressants (i.e. tricyclic
compounds), phenothiazines, benzodiazepines, antihista-
mines, bupropion, and opioids; (d) those acting on sym-
pathetic system, such as those with sympathomimetic
activity (e.g. ephedrine) and antihypertensives, including
a-1 antagonists (e.g. terazosin and prazosin), a-2 agonists
(e.g. clonidine), which can reduce salivary flow, and
b-blockers (e.g. atenolol and propranolol), which also
alter salivary protein levels; and (e) those that deplete flu-
ids, such as diuretics. The risk of xerostomia increases
with the synergistic effects of xerogenic medications,
multiple medications, higher doses of medication, and
the duration of the medication.19 These drugs include
opioids, antihistamines, antidepressants, anti-epileptics,
anxiolytics, sedatives, bronchodilators, and anticholinergic
drugs, which are often employed in palliative care.20
Salivary gland hypofunction and chronic xerostomia
can also be associated with advanced stages of HIV infec-
tion; endocrine disorders; such as uncontrolled diabetes;
S. Anil et al.
thyroid and adrenal gland diseases, graft-versus-host
disease following allogeneic or autologous hematopoietic
stem cell transplantation; malnutrition and protein defi-
ciency due to anorexia or bulimia; chronic or neurogenic
pain; smoking tobacco and cannabis; and drinking alco-
hol or caffeinated fluids.6
Xerostomia and SGH could be associated with the fol-
lowing: (a) factors affecting the salivary center: neuro-
genic; (b) factors that alter autonomic secretion of saliva:
physiological; and (c) changes in the function of the
gland itself: pathological.
Diagnosis of xerostomia
Salivary flow rates or sialometry provide surrogate infor-
mation on salivary gland function, and are therefore
important diagnostic aids in ascertaining salivary gland
pathology. Salivary flow rates can be measured in many
different ways, either from each major gland or from a
mixed sample of the oral fluids, termed “whole saliva”.
Biopsy and subsequent microscopic examination of labial
minor salivary glands have been routinely used in the diag-
nosis of major gland pathology. The diagnosis of xerosto-
mia can be established using the above, as well as a
comprehensive overall dental and medical evaluation.8,21
Questionnaires, in conjunction with sialometry, have
been used to determine subjective measurement of dry
mouth, and the usefulness of clinically-significant ques-
tions concerning dry mouth has also been suggested.22,23
Several tests are used to measure dryness of the mouth.
Salivary secretion tests, such as the chewing gum test,
Saxon test, and paraffin test, apply stimuli of variable
intensities.24,25 These tests quantify the amount of stimu-
lated saliva. Determination of the mucosal wetness in the
resting condition, especially in bedridden patients, those
with dementia, and those with dental prostheses, cannot
be performed by using these methods. Estimation of the
mucus III has been proven to be an objective diagnostic
tool for patients with serious dry mouth, such as those
with Sj€ ogren’s syndrome.26 Tests, such as sialography,
sialoscintigraphy, sialo-ultrasonography, biopsy, and sial-
ometry of the minor salivary glands, are also performed
to assess gland function.27
Complications secondary to xerostomia
Reduction of the salivary flow leads to many conse-
quences that affect an individual’s oral and general health,
including: (a) dry mouth; (b) difficulties in oral function
(dysphagia); (c) taste disturbances; (d) difficulty in wear-
ing dentures; (e) injuries of oral mucosa; (f) oropharyn-
geal infections (e.g. changes in oral microbial flora); (g)
fungal infections (e.g. candidiasis); (h) food retention in
ª 2014 Wiley Publishing Asia Pty Ltd
Xerostomia in geriatric patients
the mouth (e.g. hyposalivation-associated caries); and (i)
mucosal changes (e.g. mucus accumulation).
Patients with xerostomia might have complaints,
including difficulty in eating, swallowing, and speaking.
Halitosis, a chronic burning sensation, altered taste per-
ception, and intolerance to spicy foods have also been
reported. Decreased salivary production can lead to oral
mucosal infections with Candida, and increase the risk
of dental caries. Denture wearers might experience
retention problems, soreness, and ulcers.28–30 Nutritional
deficiencies can arise as a result of alterations in taste,
and lack of saliva also impacts speech and communica-
tion.31,32
Candidiasis, caused by an opportunistic oral fungus
and enlargement of the salivary glands due to sialadenitis
are commonly seen in patients with moderate-to-severe
SGH. Sleep disturbances are commonly seen secondary to
xerostomia,32 which in turn can significantly diminish the
quality of life.33
Rheumatoid arthritis
Rheumatoid arthritis is a systemic disease of the connec-
tive tissue that affects approximately 1% of the world’s
population and has a three times higher prevalence in
women than in men. It has been reported that RA dis-
turbs the structure and function of salivary glands, as
reflected by changes in the salivary flow and composi-
tion.34–36 Xerostomia in patients with RA could be due to
other additional causes, such as secondary Sj€ogren’s syn-
drome and/or the use of xerogenic drugs.35,37,38
€ gren’s syndrome
Sjo
Sj€
ogren’s syndrome is a chronic systemic autoimmune
disorder of the salivary and lacrimal glands that leads to
xerostomia and keratoconjunctivitis sicca.39 An estimated
prevalence in the population is 0.6%, with the highest
prevalence occurring in the fourth or fifth decade of life.
Women are affected nine times more frequently than
men.29 Bilateral enlargement of the parotid or subman-
dibular glands is seen in 20–30% of patients in associa-
tion with hyposalivation, along with symptoms of fatigue
and arthralgia.40
Effect of menopause on salivary flow and
xerostomia
The partially- or completely-reduced production of estro-
gen during menopause can cause significant decrease in
salivary flow, resulting in hyposalivation and leading to
symptoms of xerostomia.41 Xerostomia and burning
mouth are the principal oral symptoms in menopause.42
3
Xerostomia in geriatric patients
The decrease in progesterone, and especially estrogen
levels, during menopause is principally responsible for the
oral symptoms.43
Diabetes mellitus
Patients with diabetes mellitus are prone to dry mouth,
alteration of taste, burning mouth, oral Candida, and
signs of salivary gland enlargement (mainly the parotid).
Salivary flow rates, which are often found to be signifi-
cantly reduced in patients with type 2 diabetes, might be
associated with salivary gland abnormalities.44
Radiotherapy-induced xerostomia
Dry mouth or xerostomia is one of the most common
complications during and after RT for head and neck
cancer, due to irreparable damage caused to the salivary
glands exposed to the radiation fields.45 RT of the head
and neck region causes both acute and long-term compli-
cations in salivary gland tissue and function, as well as
radiation-induced changes in salivary composition.46 Par-
otid glands exposed to radiation doses >60 Gy sustain
permanent damage, with no recovery in SGH over time.
Radiation-induced damage to the salivary glands alters
the volume, consistency, and pH of secreted saliva. Saliva
changes from thin secretions with a neutral pH to thick,
tenacious secretions with increased acidity. Other qualita-
tive changes in saliva, apart from increased viscosity
include increased organic component, altered pH,
decreased transparency, and yellow–brown discoloration.
Salivary function continues to decline for up to several
months after RT.9 Approximately 50% of patients treated
for pharyngeal cancer complain of some degree of xero-
stomia years after radiotherapy.47
The acute effects of radiation on salivary function
occur during the first week of RT, and deterioration
continues until flow rates are barely measurable at 6–
8 weeks. Acute xerostomia is a constant finding during
radiotherapy, which is often complicated by fungal infec-
tions and mucositis.48 Patients usually suffer from dry,
vulnerable, and painful oral mucosa, have difficulties in
all oral functions, and experience altered or reduced per-
ception of taste (dysgeusia). Susceptibility to dental car-
ies increases secondary to a number of factors, such as a
shift to cariogenic flora, reduced salivary pH, and loss of
mineralizing salivary components. This reduced salivary
flow might also contribute to the risk of fungal infection
and osteonecrosis of the mandible.49 Depending on the
dose received and the volume of the gland tissue irradi-
ated, xerostomia develops into an irreversible, life-long
health problem that significantly reduces patients’ quality
of life.
4 ª 2014 Wiley Publishing Asia Pty Ltd
S. Anil et al.
The management of RT-induced xerostomia is prob-
lematic. Systemic medication and local approaches can be
used to stimulate salivary production and secretion, pro-
vided that there is residual gland function.50,51 However,
it should be noted that modern advances in targeted
radiotherapy (so-called “cyber knife”) reduces major side-
effects, such as salivary gland affections and xerostomia,
to a significant extent.
Hepatitis C infection
Hepatitis C virus (HCV) is a sialotropic virus that can
cause salivary gland disorders in chronic hepatitis C infec-
tion. Xerostomia is common in patients with chronic
hepatitis C, with a prevalence of 10–35%.52 HCV appears
to trigger a lymphocytic infiltration resembling Sj€ ogren’s
syndrome.53
HIV and AIDS
Xerostomia in HIV/AIDS patients has a prevalence of
1.2–63%.5,54 Xerostomia should be considered either a
possible symptom of HIV infection or a side-effect of anti-
retroviral therapy.55 In a recent study, xerostomia was
shown to have a negative impact on the quality of life of
patients living with HIV or AIDS.56
Complete denture wearers
The wetting mechanism of saliva has a role in denture
retention and stability. It has been reported that complete
denture wearers with xerostomia have more intense sore
spots.57 Other problems encountered with xerostomia and
hyposalivation in elderly patients include difficulties in
chewing, swallowing, and speaking, as well as impaired
taste.57–59 Some management approaches that could be
taken to alleviate the above problems include: (a) regular
review to optimize denture retention and stability to help
prevent problems associated with denture wear; (b) sali-
vary substitutes, artificial saliva, and salivary stimulants
can be beneficial for denture-wearing patients in terms of
helping with adhesion and cohesion, and subsequently,
prosthesis retention;60 and (c) the use of adhesives in
patients with xerostomia and hyposalivation requires
additional care, and is often necessary to stabilize a
removable prosthesis. The combined use of artificial saliva
and denture adhesive appears to be beneficial.4
Management of xerostomia
The management of xerostomia depends on the cause
and the degree of salivary gland damage. A wide range of
therapies are available, including the use of sialogogues
S. Anil et al.
and salivary substitutes.4 The suggested therapeutic course
involves preventive measures, symptomatic treatment, and
local and systemic stimulation. The management of xero-
stomia includes: (a) pharmacological sialogogues, includ-
ing pilocarpine, neostigmine, betanechol, and mucolytic
drugs (e.g. ambroxol, bromhexine, n-acetylcysteine, carb-
ocysteine, erdosteine, cevimeline); (b) non-pharmacologi-
cal saliva secretory agents, including dietary supplements,
such as eating fruits (e.g. plums, apples, lemons, olives),
medical yeast, and lozenges with lemon juice; (c) saliva
substitutes, including mixtures of carboxymethylcellulose,
mucin, glycerin, sodium, potassium, calcium, magnesium,
chloride, and some enzymes; and (d) other measures,
including acupuncture and neuro-electro stimulation.
When residual salivary function is seen, local or sys-
temic stimulation of secretory gland produces greater
relief than salivary substitutes. For irreversible damage of
the salivary gland consequent to head and neck radiother-
apy or advanced systemic disease, palliative treatment
remains the only option.
The management of xerostomia with systemic sialo-
gogues with anticholinesterasic and cholinergic action
represents an efficient therapeutic option, although they
are usually unpopular due to their other adverse side-
effects. The application of topical sialogogues can be a
useful alternative in the treatment of reversible drug-
induced xerostomia, despite the fact that their therapeutic
effects are short term and transient, with less side-
effects.61 In the past, malic and citric acid have been used
as salivary stimulants, which are now discontinued
because of the demineralizing effect on the tooth
enamel.62 However, the use of 4.7% malic acid with xyli-
tol and fluorides showed reduced demineralization.63
Local stimulation
The chewing of gum or solid food or fruits, preferentially
acidic ones, can be very effective in stimulating salivary
flow. Low-level laser therapy stimulates salivary glands, as
well as help to regain lost function.64 Acupuncture has
also been attempted to manage xerostomia and has been
shown to be an effective method in patients undergoing
radiation therapy.65 Very low-voltage electrical stimula-
tion has also been trialed in patients with SGH.66 How-
ever, much more data are warranted before such
approaches are used for xerostomia management.
Systemic stimulation
The most commonly-used sialagogues are bromhexine,
anethole trithione, pilocarpine hydrochloride (HCl), and
cevimeline HCl, showing mixed results.10 Anethole trithi-
one acts by upregulating the muscarinic receptors to
ª 2014 Wiley Publishing Asia Pty Ltd
Xerostomia in geriatric patients
stimulate salivary flow in patients with mild SGH. How-
ever, they are ineffective in patients with severe SGH.
Pilocarpine effectively increases salivary flow and provides
symptomatic improvement. As a parasympathomimetic
agent, it stimulates the cholinergic receptors on the sur-
face of acinar cells. Current indications are for patients
following RT and for those with Sj€ ogren’s syndrome.
The combined use of anethole trithione and pilocarpine
has shown to be effective, as anethole trithione increases
the number of cell surface receptors on salivary acinar
cells, and pilocarpine stimulates the receptors.67 Cevime-
line is another parasympathomimetic agonist that has
been used for the treatment of oral dryness in patients
with Sj€ogren’s syndrome.
Palliative measures
There are many palliative measures available to alleviate
symptoms of xerostomia. Salivary substitutes and lubri-
cants with moistening properties are designed to provide
prolonged mucosal wetting.68 Products include artificial
saliva, rinses, gels, and sprays, which might contain carb-
oxymethyl cellulose, a mucopolysaccharide, glycerate
polymer gel base, or natural mucins, either singly or in
combination.
Commercial saliva substitutes are most frequently
applied for relieving the sensation of dry mouth and its
side-effects. The advantage of saliva substitutes includes
the coating and moisturizing of the oral mucosa and
teeth, while the disadvantages include their short-term
activity and lack of lasting beneficial effects on the oral
tissue. Sugar-free xylitol-containing mints, candies, and
chewing gums also help stimulate salivary flow. Dietary
modification steps include avoiding dry or acidic foods,
accompanying dry foods with frequent sips of water, and
limiting caffeinated or alcoholic beverages that cause
dehydration and oral dryness.
The regular use of topical fluoride, meticulous oral
hygiene, and a low-sugar diet are recommended for pre-
venting hyposalivation-induced caries.69 The use of topi-
cal antifungal agents in the form of rinses, ointments,
pastilles, and troches effectively prevent oral candidiasis
and angular cheilitis, both of which are common in
patients with xerostomia. Professional oral hygiene proce-
dures and meticulous oral hygiene are crucial in xeros-
tomic patients to reduce the bacterial load in the oral
cavity, and thus, the risk for halitosis and oral infection.
Summary
Saliva is essential for maintaining oral health, and a
reduced salivary flow can lead to the perception of dry
mouth and xerostomia. A salivary flow rate that is
5
Xerostomia in geriatric patients S. Anil et al.

reduced by 40–50% makes the patient symptomatic.
Xerostomia is a fairly common condition among the
elderly. It is estimated that approximately 30% of the
population aged ≥65 years have xerostomia, and several
studies have reported a higher prevalence in the elderly
than in the younger population.16,30
Mouth dryness can affect quality of life and interfere
with basic daily functions, such as chewing, swallow-
ing, and speaking. Reduced salivary volume and the
subsequent loss of antibacterial properties of saliva can
accelerate infection, tooth decay, and periodontal
disease.19,70,71
Patients experiencing reduced salivary flow suffer con-
siderable morbidity, including dental caries, mucosal
infections, dysphagia, and extensive discomfort. Current
management approaches remain palliative and are gener-
ally unsatisfactory.
A variety of approaches have been used to manage
xerostomia, including increasing the frequency of water
intake and citrus fruits in the diet, and using salivary
stimulants, such as sugar-free chewing gums or lozenges.
In patients with severe xerostomia, the use of salivary
substitutes might be required.10 Clearly, with the increas-
ing elderly population worldwide and a concomitant
increase in xerostomic patients, more research on the
pathology and management of xerostomia is urgently
warranted.
Acknowledgments
The authors would like to extend their appreciation to
the Research Centre, College of Applied Medical Sciences,
and Deanship of Scientific Research at King Saud Univer-
sity for funding this research.

treatment. J Am Dent Assoc 2003; 134: hypofunction in vulnerable elders:

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