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Xerostomia
Classification and external resources

ICD-10

K11.7, R68.2

ICD-9-CM

527.7

DiseasesDB

17880

Patient UK

Xerostomia

MeSH

D014987

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
[hide]

1 Definition

2 Signs and symptoms

3 Differential diagnosis
o

3.1 Physiologic

3.2 Drug induced

3.3 Sjgren's syndrome

3.4 Sicca syndrome

3.5 Other causes

4 Diagnostic approach

5 Treatment

6 Epidemiology

7 History

8 See also

9 References

10 External links

Definition[edit]
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[edit]

Diagram depicting mouth acidity changes after consuming food high incarbohydrates. Within 5 minutes the
acidity in the mouth drops. In persons with normal salivary flow rate, acid will be neutralized in about 20

minutes. People with dry mouth often will take twice as long to neutralize mouth acid, leaving them at higher
risk of tooth decay and acid erosion

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]

Acid erosion. Saliva acts as a buffer and helps to prevent demineralization of teeth. [10]

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 cannot 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[edit]
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[edit]
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 enhancedsympathetic drive.[11] 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][12]

Drug induced[edit]
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,pra

zosin, 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 diureticdrugs are
usually responsible.[1]

Sjgren's syndrome[edit]
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[edit]
"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[edit]
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,[13] cannabis,[14] hallucinogens,[15]or heroin,[16] 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.[17]

Diagnostic approach[edit]
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,[18]such as sialometry. This
test is simple and noninvasive, 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,[19] 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[edit]
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]

Saliva substitutes these include water, artificial salivas (mucinbased, 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 triesterspray 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]

Epidemiology[edit]
Xerostomia is a very common symptom. A conservative estimate of prevalence is about 20% in the
general population, with increased prevalences in females (up to 30%) and the elderly (up to 50%). [8]

History[edit]
Xerostomia has been used as a test to detect lies, which relied on emotional inhibition of salivary
secretions to indicate possible incrimination.[20]

See also[edit]

Xerosis (dry skin)

References[edit]
1.

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