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Review Article

Xerostomia: Few dry facts about dry mouth

Prasanna Kumar J. Rao, Laxmikanth Chatra, Prashanth Shenai, KM Veena, Rachana V. Prabhu,
Tashika Kushraj, Prathima Shetty, Shaul Hameed
Department of Oral Medicine and Radiology,Yenepoya Dental College,Yenepoya University, Mangalore, Karnataka, India

ABSTRACT
Xerostomia is the subjective feeling of oral dryness, which is often associated with hypofunction of the salivary gland. Xerostomia
can also have a major impact on a patient’s oral health and quality of life. Patients with xerostomia complaints of problems with
mastication, phonetics, deglutition and wearing dentures. Treatment of this condition always depends on the cause. Oral physicians
should be able to diagnose this condition and able to give proper treatment to provide comfort to their patients. This article reviews
the causes of xerostomia and its management.

Key words: Drymouth, saliva, salivary flow, xerostomia

Introduction disease, diabetes mellitus, viral and bacterial disease.[5-7]

Saliva plays an important role in maintaining good oral and
general health. People become aware of its importance
only when the salivary flow reduces. It causes reduction of
person’s quality of life.[1] Saliva is a complex fluid, which is
composed of 99% of water and only 1% of non organic and
organic substances[2] [Table 1]. These constituents are from
within the gland and transported from the blood.[3] The major
role of these components present in the saliva are to provide
prophylactic, therapeutic and diagnostic properties to saliva.
The compounds which are present in the saliva are also
present in the blood.[4] A large number of analytes in saliva
are discovered and some of them are used as biomarkers
different diseases such as periodontal diseases, oral cancer,
breast cancer, autoimmune diseases, HIV, cardiovascular
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DOI:
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Because of molecular diagnostics and nanotechnology, saliva
is becoming valuable source of diagnostic information.[8]
In the oral cavity saliva serves many functions[9] [Table 2].
It helps in normal functioning of oral cavity. It is also very
important for better retention of dentures in the oral cavity.[9]
Salivary Flow Assessment
Saliva secreted in the oral cavity by three pairs of major
salivary glands and hundreds of minor salivary glands which
are distributed throughout the oral cavity [Table 3].[10] Flow
rates of saliva gives information about function of salivary
glands. There are different methods used to evaluate the
salivary gland secretion and drymouth. These methods
includes self-reported questionnaires, visual analog scales
(VAS), simple functional measures by using mouth mirrors,
by asking the patient to chew and swallow dried biscuits with
water, sialography, sialoscintigraphy, sialoultrasonography,
sialometry of the minor salivary glands and biopsy.[11] Other
methods are by measuring volume of residual saliva on
mucosal surfaces using filter paper and micromoisture
meter and calculating thickness, and using mucosal wetness
devices.[12]

Corresponding Author:
Dr. Prasanna Kumar J Rao, Department of Oral Medicine and Radiology,Yenepoya Dental College,Yenepoya University,
Mangalore - 575 018, Karnataka, India. E-mail: drjpkrao@gmail.com

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Table 1: Non-organic and organic substances of saliva
Enzymes
Hormones
Antibiotics
Antimicrobial constituents
Growth factors
Table 2: Uses of saliva
Digestion
Masticatory function
Swallowing
Speech
Improves taste
Lubricates oral mucosa
Free movements of oral tissues
Maintaining mucosal integrity
Irrigation and cleansing of teeth
Protect teeth from demineralization
Anti microbial and immunological protection against oral infection
Retention and comfort of denture
Saliva as a diagnostic tool
Table 3: Estimated salivary flow rates
Parotid gland
Submandibular gland
Sublingual gland
Minor salivary glands
Among these methods sialometry is the most objective
method to assess salivary function. This method is used
to determine the quantity of both resting and stimulated
whole saliva.[13] In a normal individuals daily secretion
of saliva is approximately 1.5 L per day (0.5-1mL/min).
This normal flow rate also varies due to diurinal variation,
hydration, food intake and other factors. Unstimulated
wholesaliva flow rate less than 0.1 mL/min and stimulated
salivary flow rate less than 0.5 mL/min, respectively, is
an indication for hyposecretion of saliva or hyperfunction
of salivary glands. Functioning of parotid saliva can be
done by collecting exclusive parotid saliva using carlson
crettinden cups.[14]
Hypofunction and hyposalivation is a subjective complaint
of oral dryness due to various causes, the condition termed
as xerostomia. This term was derived from Greek word
‘xeros’ (dry) and ‘stoma’ (mouth).[11] It is the most common
complaint why a patient visits a dental specialist. This
condition adversely affects an oral function which leads to
oral sequelae-like mucosal dryness, difficulty in speech,
chewing and swallowing, oral burning sensation, increased
fungal infection, demineralization of teeth, halitosis and
difficulty in wearing dentures.[15]
The following questions should be asked to detect
drymouth.[16]
• Do you sip liquids to aid in swallowing dry foods ?
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Rao, et al.: Dry mouth
• Does your mouth feels dry when eating a meal ?
• Do you have difficulties swallowing any foods ?
• Does the amount of saliva in your mouth seem to be too
little ?
• Does your nose or throat feel dry and tickly ?
• Do you have a dry cough, hoarseness, nose bleeds or
decreased sense of taste or smell ?
Patients who respond positive to these questions with
salivary flow rate less than 0.1 mL/ min are diagnosed as
salivary hypofunction.
Causes of Xerostomia
The prevalence of xerostomia in general population is
varying. But prevalence with Sjogren’s syndrome and
patients receiving radiotherapy for head and neck cancer
was 100%.[17] The studies shows that prevalence increases
with age and it is more in postmenopausal women (10.3-
65% ~ 0.26 mL/min 33.7%) compared to men (9.7-25.8%).[18] It is important
20%-30% ~ 0.08 mL/min
6% ~ 0.03 mL/min
to note that multidimentional factors are associated with
5% ~ 0.03 mL/min xerostomia. Emotional disorders, such as a panic attack
caused by severe anxiety, may cause dry mouth due to
the stress or “flight or fight” response, which reduces
saliva production in the mouth. In such condition patient
complains of dryness of mouth but on sialometry there is
no abnormality detected. It is also a problem in a young
patients particularly those who taking antidepressant
drugs [Figure 1].[19]
This condition has variety of causes, which is divided in to
two main categories:[2] [Table 4]
• Direct causes — Primary causes or direct causes are
the conditions which directly affect the salivary glands
and decrease the salivary flow rate.[20] The most common
autoimmune disease which is associated with xerostomia is
Sjogrens syndrome [SS]. It is charecterized by inflammation
of exocrine glands. The primary SS or sicca syndrome
shows only eye and oral symptoms. In SS lymphocytic
infiltration destroys the secretory acini of major and minor
salivary glands and causes hyposalivation.[21]
• Indirect causes — Secondary causes or indirect
causes are conditions in which Xerostomia is the
side effect. Irradiation and cytotoxic drugs causes
sialadenitis which causes irreversible damage to
acinar cells.[3] It is also a side effect of variety of other
autoimmune disorders.
Among the most commonly prescribed drugs around 80%
of the drugs causes xerostomia.[22] Around 42 categories
and 56 sub-categories of drugs shows adverse effect of
xerostomia[1] [Table 5].
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Rao, et al.: Dry mouth

Table 4: Direct and indirect causes of xerostomia

Primary or Direct causes Secondary or indirect causes
Sjogrens syndrome Radiation therapy
Type 1 and 2 diabeties mellitus Chemotherapy
Gestational diabeties Drugs
Thyroid disease Rheumatoid disorders
Adrenal conditions Scleroderma
Renal and hepatic diseases Mixed connective tissue diseases
Hepatitis C viral infection Systemic erythematus lupus
HIV Graft versus host disease
Anorexia and bulimia
Alcohol
Smoking tobacco

Table 5: Drugs associated with xerostomia

Figure 1: Causes of xerostomia
Drugs which directly damages salivary glands Cytotoxic drugs
Drugs with ant cholinergic activity Anticholinergic agents–Atropine,

Dental Implications Atropinics and hyoscine

Xerostomia affects the quality of life of patients. These
patients may be asymptomatic or frequently complain of dry
mouth which develops many complications. Patients with dry
mouth experience various oral symptoms. There are many
consequences and complications of xerostomia[23] [Table 6].
• Oral mucosa — It is very sensitive, prone to injuries and
damage, burning sensation, altered taste and halitosis.
In case of radiotherapy oral mucosa becomes dry and
large ulcers appear in the path of radiation.[24]
• Dentures — Lack of lubrication due to drymouth causes
traumatic mucosal ulcers, increased susceptibility of
fungal infections causes difficulties in wearing dentures.
Using flexible dentures in radiation induced patients
with minimal tissue damage during and after denture
construction procedures.[25]
• Caries — Dry mouth increase the risk of generalized
caries, enamel erosion and periodontal diseases. It
decreases the oral pH which causes increased plaque
accumulation and dental caries. Radiation-induced
caries is common in patients who is undergoing head
and neck radiotherapy.[26]
• Fungal infection — In moderate to severe case
of salivary gland hypofunction oral candidiasis and
salivary gland enlargement due to sialadenitis is
seen. Risk of fungal infection increases in patients
who wear dentures, smoking and alcohol habits and
diabetics. [1]
Management
Management of xerostomia is based upon the cause and
severity of salivary gland damage. So treatment comprises
of etiologic, stimulative, symptomatic or palliative
approach. Patients with dry mouth should increase intake
of water. They should be advised to place ice chips in the
Antireflux agents–Proton pump inhabitors
Central acting psychoactive agents Antidepressants
Phenothiazines
Benzodiazepines
Antihistamines
Bupropin
Opioids
Drugs acting on sympathetic systems Drugs with sympathomimetic activity
Antihypertensive-alpha 1 and alpha @
antagonists and Beta blockers
Drugs that deplete fluids Diurerics
Table 6: Complications of xerostomia
Thirst
Dysphasia
Altered taste
Difficulties in speech
Difficulties in wearing dentures
Injuries to oral mucosa
Burning mouth
Plaque accumulation
Caries
Oral infections
Nocturnal oral discomfort
Psychiatric symptoms like depression and anxiety
mouth or sip water every 5-10 minutes to provide moisture
in the mouth.[1] Patients with remaining salivary function,
acidic taste provided by sugar-free chewing gums, solid
food or fruits can effectively stimulate salivary flow. In
such patients we should advise to reduce sweet foods to
prevent dental caries and increase water intake. Patients
with drymouth should avoid spicy foods, dry foods and
hard crunchy foods. They should dunk them in liquids.
Advice them to eat such foods with small bites and eat
slowly. Advice to eat soft creamy foods or cool foods
with high liquid content like watermelon, grapes, and
icecreams. Water or non-alcoholic drinks with meals will
also helps. Lips can be protected by applying lip salve or
petroleum jelly.[16]
Patients with drymouth are at high risk for dental caries
and halitosis. An extra effort is needed to protect against

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decalcification of teeth, dental decay and halitosis by reducing
sugar intake, avoiding sticky foods such as toffee, keeping
mouth very clean by brushing twice daily and flossing, using
fluoride tooth paste, using fluoride jells or mouth washes
daily. They should go for regular dental checkups. Thorough
dental checkup with bitewing radiographs are necessary to
detect any new carious lesions.[16]
There is high risk of periodontal diseases in drymouth
patients. Proper oral hygienemaintenance and use of electric
tooth brush helps to effectively remove plaque. These
patients areadvised to receive periodontal prophylaxis every
3 months to reduce periodontal disease. Use of antibacterial
mouth washes may reduce gingivitis.[27]
Oral candidiasis is commonly seen in patients with xerostomia.
These patients should be prescribed topical antifungal agents.
When topical medication is ineffective, systemic antifungal
medications are recommended.[27] Non-selective muscarinic
receptor agonists such as pilocarpine or civemiline will
increase salivary function in patients with xerostomia. Oral
lubricants like vitamin E or oral balance also helpful in case of
drymucosa and cracked lips. Tooth-whitening products should
be avoided because they irritate the oral tissues [Table 7].[27]
Few studies also proved that use of acupuncture in the
management of xerostomia is effective in increasing
the saliva flow rate. Electrical stimulation therapy also
used in salivary hypofunction.[28] In case of drugs which
causexerostomia, dentist should consult the patient’s
physician and request him to prescribe an alternative drug
which employs other mode of action. Advice the patient to
avoid taking medications before bedtime because salivary
flow rate is low during sleep.[29]
Summary
Xerostomia is a subjective perception of oral dryness.
There may be various degree of salivary hypofunction
Table 7: Management of xerostomia
Reduced salivary Caries prevention Periodontal disease Fungal infection
gland function prevention
Sugar free chewing Oral hygiene Oral hygiene
gum maintenance maintenance
Increased water intake Non alcoholic drink Use of electric tooth
brush
Petrolium jelly for Decrease sweet intake Antibacterial mouth
dry lips wash
Vitamin E oral Fluroide application
lubricants
Pilocarpine Regular dental
check-up
Civemiline
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Rao, et al.: Dry mouth
depending upon the causes. Early diagnosis and
treatment can slow progression of dry mouth and
improve the quality of life of the patient. Routine follow-
up care between the physician and dentist is necessary
to prevent xerostomia.
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How to cite this article: Rao PJ, Chatra L, Shenai P, Veena KM, Prabhu
RV, Kushraj T, et al. Xerostomia: Few dry facts about dry mouth. Arch Med
Health Sci 2014;2:190-4.
Source of Support: Nil, Conflict of Interest: None declared.

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