Xerostomia (Dry Mouth)

Key Points

  • Severity of xerostomia or dry mouth symptoms ranges from mild oral discomfort to significant oral disease that can compromise the patient’s health, dietary intake, and quality of life.
  • Causes of dry mouth can include toxicity from chemotherapy, head and neck radiotherapy, adverse effects of medications, autoimmune disease, or other conditions (e.g., uncontrolled diabetes, infections, hormonal changes). Xerostomia occurs commonly in those with Sjögren disease or who are receiving radiation therapy for head and neck cancer.
  • Reduced salivary flow can cause difficulties in tasting, chewing, swallowing, and speaking; it can also increase the chance of developing dental decay, demineralization of teeth, tooth sensitivity, and/or oral infections.
  • The goals of treating xerostomia include identifying the possible cause(s), relieving discomfort, and preventing complications (e.g., dental caries and periodontal infections).
  • Xerostomia may be alleviated by use of saliva substitutes and other palliative measures; lifestyle tips (e.g., chewing sugar-free gum) and other dental/oral health specific recommendations (e.g., brushing teeth gently at least twice a day with fluoridated toothpaste) may help provide relief from or prevent adverse sequelae of dry mouth.
Introduction

Xerostomia or dry mouth, is a common, but sometimes overlooked, condition that is typically associated with salivary gland hypofunction (i.e., the objective measurement of reduced salivary flow).1, 2 Reduced salivary flow can cause difficulties in tasting, chewing, swallowing, and speaking; it can also increase the chance of developing dental decay, demineralization of teeth, tooth sensitivity, and/or oral infections.2, 3 There are a variety of potential causes of xerostomia, including adverse effects of medication, toxicity of chemotherapy and/or radiation therapy of the head and neck, autoimmune disease, other chronic disease, and nerve damage.4 Patients can be variably affected.4

Background

Severity of dry mouth symptoms ranges from mild oral discomfort to significant oral disease that can compromise the patient’s health, dietary intake, and quality of life.1, 2 Estimates of xerostomia prevalence in the general population are imprecise because of limited data; estimates range from 0.9% to 64.8%.5 In people with Sjögren disease or in those receiving radiation therapy for head and neck cancer, the prevalence approaches 100%.5

Saliva is a mixture of secretions from the major (i.e., parotid, submandibular, sublingual) and minor salivary glands.6 In healthy individuals, the daily production of saliva normally ranges from 0.5 to 1.5 liters.7 Saliva is 99% water and contains a number of electrolytes (e.g., sodium, potassium, calcium, bicarbonate, phosphate) and organic components (e.g., immunoglobulins, proteins, enzymes, mucins).6, 8 In addition to keeping tissues moist and helping to digest food, saliva cleanses the oral cavity, makes it possible to chew and swallow food, maintains a neutral pH, and prevents demineralization.1, 3 Salivary proteins and mucins contribute to the lubrication and coating of oral tissues, protecting the mucosa from chemical, microbial, and physical injury.1-3  Without adequate salivary flow, tooth decay and a variety of oral infections can develop.3, 6 Xerostomia symptoms may also worsen at night because salivary output reaches its lowest circadian levels during sleep and the problem can be exacerbated by mouth breathing.9

Reduced salivary flow can interfere with chewing or swallowing certain foods which may result in malnutrition.3 Significant loss of salivary gland function is associated with altered taste sensation (i.e., dysgeusia).1, 2, 7

Causes of Xerostomia

Drug/Therapy-Related

Medication-Induced Xerostomia.  The most frequent cause of hyposalivation is use of certain medications.10 According to the Surgeon General’s Report on Oral Health in America,11 more than 400 over-the-counter (OTC) and prescription medications can contribute to or exacerbate oral dryness, including antihistamines (for allergy or asthma), antihypertensive medications, decongestants, pain medications, diuretics, muscle relaxants, and antidepressants.4-6, 12 The most common types of medications causing salivary dysfunction have anticholinergic effects, e.g., tricyclic antidepressants, antihistamines, antihypertensive medications, and antiseizure/antispasmodic drugs.13 Patients who are taking multiple medications may also be at a higher risk of dry mouth as an adverse effect of therapy.9

Drug substitutions may help reduce the dry mouth effects of certain medications (e.g., selective serotonin-reuptake inhibitor antidepressants tend to cause less dry mouth than tricyclic antidepressants).9, 13, 14 Dry mouth symptoms from medications may also be reduced if patients who are taking anticholinergic medications can take them during the day, rather than at night (avoiding nocturnal symptoms), and in divided doses, rather than one larger, single dose (potentially avoiding the xerostomic adverse effects of a larger dose).9, 13

Toxicity Related to Cancer Chemotherapy or Head and Neck Cancer Radiotherapy.  Oral complications of cancer chemotherapy or head and neck cancer radiotherapy6, 13, 15 can be acute (i.e., develop during therapy) or chronic (i.e., develop months to years after therapy).15 These therapies can cause xerostomia/salivary gland hypofunction via direct toxicity to salivary glands and oral tissues or indirect damage due to regional or systemic toxicity.13, 15 Generally, cancer chemotherapy causes acute toxicities that resolve following discontinuation of therapy and healing of damaged tissue, whereas radiation therapy can cause acute oral toxicity, as well as induce permanent tissue damage that can put patients at lifelong risk.13, 15 Xerostomia can also occur following hematopoietic stem-cell transplantation.15 Sialadenitis, or infection of the salivary gland, is another potential acute oral toxicity associated with chemo/radiotherapy.15 Radioactive iodine, which is used to treat some thyroid cancers, can damage salivary glands (primarily the parotid glands) in a dose-dependent fashion.9, 13

Physiological or Disease-Related

Aging. Xerostomia affects 30% of patients older than 65 years and up to 40% of patients older than 80 years; this is primarily an adverse effect of medication(s), although it can also result from comorbid conditions such as diabetes, Alzheimer’s disease, or Parkinson’s disease.16-18 Xerostomia, while common among older patients, is more likely to occur in those with an intake of more than four daily prescription medications.18

Autoimmune Disease.  Sjögren disease (formerly known as Sjögren syndrome)19 is the second most common autoimmune connective-tissue disease19 and is the systemic condition most frequently associated with salivary dysfunction and xerostomia.9  Although Sjögren disease is a systemic condition that can affect any body organ or system, the primary symptoms are dry mouth and dry eyes.3, 6, 19 Sjögren disease causes chronic inflammation and dysfunction, resulting in salivary gland damage.19  Primary Sjögren disease (i.e., Sjögren disease alone) affects approximately 1 in 70 people; this number approximately doubles if patients with other major autoimmune or rheumatic disease in addition to Sjögren disease are included19 (i.e., secondary Sjögren disease9). Other autoimmune diseases that can occur with Sjögren disease include rheumatoid arthritis, systemic lupus erythematosus, scleroderma, polymyositis, and polyarteritis nodosa.9

Other Conditions.  Other conditions associated with dry mouth include:1-4, 6, 12

  • Cystic fibrosis
  • Graft-versus-host disease
  • Hepatitis C virus infection
  • HIV infection/AIDS
  • Hormonal changes (e.g., pregnancy or menopause)
  • Lymphoma
  • Nerve damage from a head or neck injury
  • Poorly controlled diabetes
  • Psychogenic causes
  • Salivary gland agenesis or aplasia
  • Stroke
  • Uncontrolled hypertension

Potential lifestyle causes of xerostomia include the use of alcohol or tobacco, or the consumption of excessive caffeine or spicy food.4

Signs and Symptoms

Xerostomia can cause the following complications:1-3, 10, 12, 13, 20

  • a sticky, dry, or burning feeling in the mouth
  • trouble chewing, swallowing, tasting, or speaking
  • altered taste or intolerance for spicy, salty, or sour foods or drinks
  • a dry or sore throat
  • cracked, peeling, or atrophic lips
  • a dry, rough tongue
  • mouth sores
  • an infection in the mouth
  • hoarseness
  • halitosis (bad breath)
  • inability to retain dentures or otherwise poorly fitting removable prostheses
Dental Implications of Xerostomia

The goals of treating xerostomia include identifying the possible cause(s), relieving discomfort, and preventing complications, e.g., dental caries and periodontal infections.4

Identification

Patients with complaints of dry mouth should have a detailed health history (medical and dental) performed to help with early detection and identification of potential underlying causes.1, 2, 9 In patients with xerostomia or salivary gland hypofunction, oral examination may reveal dry and friable oral mucosa and the tongue may appear dry and fissured.1, 2, 5 Patients may commonly have dental caries (especially root, cervical, or incisal/cuspal tips), plaque accumulation, gingivitis, and/or periodontitis.1, 2, 5, 20 Infections (e.g., oral candidiasis) and enlargement of salivary glands from sialadenitis may also be present.1, 2, 5, 9, 20 Other oral manifestations evident on examination may include angular cheilitis, mucositis, traumatic oral lesions, and/or difficulty in wearing/retaining oral prostheses.5, 9, 20

A thorough head and neck examination, including an intraoral evaluation to identify the presence or absence of salivary pooling on the floor of the mouth, can help a dentist identify who will benefit from further diagnostic evaluations, such as salivary flow rate measurement, minor salivary gland biopsy, or blood and microbial tests.1, 2 A patient is considered to have reduced salivary flow if the unstimulated salivary flow is 0.1 mL/min or less (measured for 5 to 15 minutes) or if the chewing-stimulated salivary flow is 0.7 mL/min or less (measured for 5 minutes).5, 20

General Palliative/Preventive Interventions

Management of xerostomia and hyposalivation should emphasize patient education and lifestyle modifications.1, 2 Various palliative and preventive measures, including pharmacologic treatment with salivary stimulants, topical fluoride, saliva substitutes, and use of sugar-free gum/mints may alleviate some symptoms of dry mouth and may improve a patient’s quality of life.1, 2, 5

Patients should be counseled on lifestyle tips for relieving dry mouth; these include:9, 12

  • sipping water or sugarless, caffeine-free drinks
  • sucking on ice chips
  • using lip lubricants frequently (e.g., every 2 hours)
  • chewing sugar-free gum or sucking on sugar-free candy9
  • avoiding salty or spicy food or dry, hard-to-chew foods9
  • avoiding sticky, sugary foods
  • avoiding irritants such as alcohol (including alcohol-containing mouth rinses5), tobacco, and caffeine
  • drinking fluids while eating carefully6, 9
  • using a humidifier at night9

Dental and oral health-specific recommendations from the National Institute for Dental and Craniofacial Research3 and others5, 9, 13 include the following for patients with dry mouth:

  • brush teeth gently at least twice a day with fluoridated toothpaste
  • floss teeth every day
  • schedule dental visits at least twice a year (with yearly bitewing radiographs)
  • use of a prescription-strength fluoride gel (0.4% stannous fluoride, 1.0% sodium fluoride) daily to help prevent dental decay
  • prompt treatment of oral fungal or bacterial infections
  • application of 0.5% fluoride varnish to teeth
  • dental soft- and hard-tissue relines of poorly fitting prostheses and use of denture adhesives

Salivary Stimulants.  Salivary stimulants should be considered in patients with residual salivary gland function.9, 12  Sugar-free chewing gum, candies, and mints can be used to stimulate salivary output.9 The FDA has approved the oral secretagogues pilocarpine (Salagen®, Eisai and generics)21 and cevimeline hydrochloride (Evoxac® capsules, Daiichi-Sankyo and generics)22 to treat symptoms of dry mouth.10, 13 Pilocarpine is typically administered at a dose of 5 mg three times a day for at least 3 months and cevimeline is prescribed at a dose of 30 mg three times a day for at least 3 months.10  Adverse effects include sweating, cutaneous vasodilation, nausea and vomiting, diarrhea, hiccup, hypotension and bradycardia, increased urinary frequency, bronchoconstriction, and vision problems.10

Artificial Saliva/Saliva Substitutes/Oral Moisturizers. Artificial saliva products are available with or without prescription.  They typically contain a combination of carboxymethylcellulose and glycerin to increase viscosity, as well as buffering and flavoring agents (e.g., sorbitol, xylitol), and calcium and phosphate ions;4, 23 however, they do not contain the digestive and antibacterial enzymes or other proteins and minerals of biologic saliva.23 Some products also contain fluoride.4 A prescription-only product, NeutraSal® (OraPharma, Inc.), is a supersaturated calcium phosphate rinse available as powder for reconstitution.24

The ADA Seal of Acceptance category for products for temporary relief of dry mouth means that the product is safe and has shown efficacy in temporarily relieving dry mouth symptoms, when used as directed.

Saliva substitutes are used as often as needed and although they do not cure dry mouth, they can provide temporary relief of symptoms.4, 23 Alcohol-free mouth rinses, lozenges, and moisturizing oral sprays and gels are marketed as OTC oral care options for patients with dry mouth.4, 6, 9 There are also toothpastes specifically formulated for use in patients with dry mouth.4, 6

A 2011 Cochrane Review25, 26 found “no strong evidence” that any specific topical therapy (e.g., sprays, lozenges, mouth rinses, gels, oils, chewing gum, or toothpastes) was effective for relieving the symptoms of dry mouth. Although chewing gum was shown to increase saliva production, there was no strong evidence that dry mouth symptoms were improved. The authors noted that “patient preference is an important consideration, together with consideration of the potential adverse effects.” The review concluded that, “Well designed, adequately powered randomised controlled trials of topical interventions for dry mouth, which are designed and reported according to CONSORT guidelines, are required to provide evidence to guide clinical care.”

References
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  8. Furness S, Bryan G, McMillan R, Birchenough S, Worthington HV. Interventions for the management of dry mouth: Non-pharmacological interventions. Cochrane Database Syst Rev 2013(9):Cd009603.

  9. Agostini BA, Cericato GO, Silveira ERD, et al. How common is dry mouth? Systematic review and meta-regression analysis of prevalence estimates. Braz Dent J 2018;29(6):606-18.

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  19. U.S. Food and Drug Information Dry mouth? Don't delay treatment. Consumer Health Information. "https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm254273.htm". Accessed July 2, 2019.

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  21. Ship JA. Diagnosing, managing, and preventing salivary gland disorders. Oral Dis 2002;8(2):77-89.

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ADA Resources
What products have earned the ADA Seal of Acceptance?
Get a Complete List of ADA Accepted Mouthrinses

Professional Resources

Patient Resources
ADA MouthHealthy:
JADA “For the Patient” pages

ADA Catalog: Dry Mouth Patient Brochure (Item #W279)


Other Resources
2016 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for primary Sjögren's syndrome
American Academy of Oral Medicine: Xerostomia
Mayo Clinic: Dry Mouth
MEDLINE Plus (U.S. National Library of Medicine): Dry Mouth
National Institute for Dental and Craniofacial Research: Dry Mouth
Sjögren's Syndrome Foundation, Inc.

Last Updated: February 22, 2021

Prepared by:

Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC.


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