Xerostomia Explained


Xerostomia, also known as dry mouth[1] and dry mouth syndrome, is dryness in the mouth, which may be associated with a change in the composition of saliva, or reduced salivary flow, or have no identifiable cause.



Xerostomia is the subjective sensation of dry mouth, which is often (but not always) associated with hypofunction of the salivary glands.[2] The term is derived from the Greek words ξηρός (xeros) meaning "dry" and στόμα (stoma) meaning "mouth".[3] [4] A drug or substance that increases the rate of salivary flow is termed a sialogogue.

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.[5] An unstimulated whole saliva flow rate in a normal person is 0.3–0.4 ml per minute,[6] 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 clinical evidence of dryness . Xerostomia may also result from a change in composition of saliva (from serous to mucous).[5] Salivary gland dysfunction is an umbrella term for the presence of either xerostomia or salivary gland hypofunction.[5]

Signs and symptoms

True hyposalivation may give the following signs and symptoms:

However, sometimes the clinical findings do not correlate with the symptoms experienced.[8] 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). In the latter scenario, there are often other oral symptoms suggestive of oral dysesthesia ("burning mouth syndrome").[2] Some symptoms outside the mouth may occur together with xerostomia.

These include:

There may also be other systemic signs and symptoms if there is an underlying cause such as Sjögren'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. Altered saliva composition may also be responsible for xerostomia.


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.[9] 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.[8] [10]

Drug induced

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.[2] Over 400 medications are associated with xerostomia, some of these are listed in table 1. Although drug induced xerostomia is commonly reversible, the conditions for which these medications are prescribed are frequently chronic. The likelihood of xerostomia increases in relation to the total number of medications taken, whether the individual medications are xerogenic or not.[8] 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]

Sjögren's syndrome

See main article: article and Sjögren's syndrome. Xerostomia may be caused by autoimmune conditions which damage saliva producing cells . Sjögren's syndrome is one such disease, and it's associated with symptoms including fatigue, myalgia and arthralgia . The disease is characterised by inflammatory changes in the moisture producing glands throughout the body, leading to reduced secretions from glands that produce saliva, tears and other secretions throughout the body . Primary Sjögren's syndrome is the combination of dry eyes and xerostomia. Secondary Sjögren'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.

Radiation Therapy

Radiation therapy for cancers of the head and neck (including brachytherapy for thyroid cancers) where the salivary glands are close to or within the field irradiated is another major cause of xerostomia . A radiation dose of 52 Gy is sufficient to cause severe salivary dysfunction. Radiotherapy for oral cancers usually involves up to 70 Gy of radiation, often given alongside with chemotherapy which may also have a damaging effect on saliva production .

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,[2] usually caused by partial obstruction of the upper respiratory tract. Examples include hemorrhage, vomiting, diarrhea, and fever.[1] [8]

Alcohol may be involved in the cause of salivary gland disease, liver disease, or dehydration.[2]

Smoking is another possible cause.[8] Other recreational drugs such as methamphetamine,[11] cannabis,[12] hallucinogens,[13] or heroin,[14] may be implicated.

Hormonal disorders, such as poorly controlled diabetes, chronic graft versus host disease or low fluid intake in people undergoing haemodialysis for renal impairment may also result in xerostomia, due to dehydration .

Infection with Human Immunodeficiency Virus/Acquired immunodeficiency Syndrome (AIDS) can cause a related salivary gland disease known as Diffuse Infiltrative Lymphocytosis Syndrome (DILS)

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,[15] 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 Sjögren's syndrome or neoplasia).[1] A minor salivary gland biopsy, usually taken from the lip,[16] 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]


The successful treatment of xerostomia is difficult to achieve and often unsatisfactory.[8] 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. The management of salivary gland dysfunction may involve the use of saliva substitutes and/or saliva stimulants:

Saliva substitutes can improve xerostomia, but tend not to improve the other problems associated with salivary gland dysfunction. Parasympathomimitic drugs (saliva stimulants) such as pilocarpine may improve xerostomia symptoms and other problems associated with salivary gland dysfunction, but the evidence for treatment of radiation-induced xerostomia is limited.[17] Both stimulants and substitutes relieve symptoms to some extent.[18] Salivary stimulants are probably only useful in people with some remaining detectable salivary function.[2] A systematic review compromising of 36 randomised controlled trials for the treatment of dry mouth found that there was no strong evidence to suggest that a specific topical therapy is effective. This review also states that topical therapies can be expected to provide only short-term effects, which are reversible. The review reported limited evidence that oxygenated glycerol triester spray was more effective than electrolyte sprays. Sugar free chewing gum increases saliva production but there is no strong evidence that it improves symptoms. Plus, there is no clear evidence to suggest whether chewing gum is more or less effective as a treatment. 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. 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.[5] 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).[5] Improvements can take up to twelve weeks.[5] However, pilocarpine is not always successful in improving xerostomia symptoms.[5] The review also concluded that there was little evidence to support the use of other parasympathomimetics in this group.[5] Another systematic review showed, that there is some low-quality evidence to suggest that amifostine prevents the feeling of dry mouth or reduce the risk of moderate to severe xerostomia in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short- (end of radiotherapy) to medium-term (three months postradiotherapy). But, it is less clear whether or not this effect is sustained to 12 months postradiotherapy.[19]

A 2013 review looking at non-pharmacological interventions reported a lack of evidence to support the effects of electrostimulation devices, or acupuncture, on symptoms of dry mouth.[20]


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%).[21] Estimates of the prevalence of persistent dry mouth vary between 10 and 50% [21] .


Xerostomia has been used as a test to detect lies, which relied on emotional inhibition of salivary secretions to indicate possible incrimination.[22]

See also

External links

Notes and References

  1. Book: Scully, Crispian. Oral and maxillofacial medicine : the basis of diagnosis and treatment. Churchill Livingstone. 2008. 9780443068188. 2nd. Edinburgh. 17, 31, 41, 79–85.
  2. Book: Tyldesley, Anne Field, Lesley Longman in collaboration with William R.. Tyldesley's Oral medicine. 2003. Oxford University Press. Oxford. 0192631470. 19, 90–93. 5th.
  3. Web site: Etymology of "xeros" at Online Etymology Dictionary. Douglas Harper. 9 February 2013.
  4. Web site: Etymology of "stoma" at Online Etymology Dictionary. Douglas Harper. 9 February 2013.
  5. Davies. AN. Shorthose, K. Parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy. Cochrane Database of Systematic Reviews. Oct 5, 2015. 10. CD003782. 26436597. 10.1002/14651858.CD003782.pub3.
  6. Book: Coulthard, Paul. etal. Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine. 2008. Churchill Livingstone/Elsevier. Edinburgh. 9780443068966. 210, 212–213. 2nd.
  7. Hara. AT. Zero. DT. The potential of saliva in protecting against dental erosion.. Monographs in oral science. 2014. 25. 197–205. 24993267. 10.1159/000360372.
  8. Book: Bouquot, Brad W. Neville, Douglas D. Damm, Carl M. Allen, Jerry E.. Oral & maxillofacial pathology. 2002. W.B. Saunders. Philadelphia. 0721690033. 398–399. 2..
  9. Boyce. HW. Bakheet, MR. Sialorrhea: a review of a vexing, often unrecognized sign of oropharyngeal and esophageal disease. Journal of Clinical Gastroenterology. February 2005. 39. 2. 89–97. 15681902.
  10. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. Journal of the American Dental Association (1939). 138. 1. 15S–20S. September 2007. 17761841. 10.14219/jada.archive.2007.0358. yes.
  11. Saini. T. Edwards, PC. Kimmes, NS. Carroll, LR. Shaner, JW. Dowd, FJ. 2005. Etiology of xerostomia and dental caries among methamphetamine abusers. Oral health & preventive dentistry. 3. 3. 189–95. 16355653.
  12. Versteeg. PA. Slot. DE. van der Velden. U. van der Weijden. GA. Nov 2008. Effect of cannabis usage on the oral environment: a review. International journal of dental hygiene. 6. 4. 315–20. 10.1111/j.1601-5037.2008.00301.x. 19138182.
  13. Fazzi. M. Vescovi, P. Savi, A. Manfredi, M. Peracchia, M. October 1999. [The effects of drugs on the oral cavity]. Minerva stomatologica. 48. 10. 485–92. 10726452.
  14. Web site: DrugFacts: Heroin on National Institute of Drug Abuse. National Institutes of Health. 9 February 2013.
  15. Visvanathan. V. Nix, P. Managing the patient presenting with xerostomia: a review. International journal of clinical practice. February 2010. 64. 3. 404–7. 19817913. 10.1111/j.1742-1241.2009.02132.x.
  16. Fox. PC. van der Ven. PF. Sonies. BC. Weiffenbach. JM. Baum. BJ. Xerostomia: evaluation of a symptom with increasing significance. Journal of the American Dental Association (1939). April 1985. 110. 4. 519–25. 3858368.
  17. Davies. AN. Thompson. J. Parasympathomimetic drugs for the treatment of salivary gland dysfunction due to radiotherapy.. The Cochrane Database of Systematic Reviews. 5 October 2015. 10. CD003782. 26436597. 10.1002/14651858.CD003782.pub3.
  18. Björnström. M. Axéll. T. Birkhed. D. Comparison between saliva stimulants and saliva substitutes in patients with symptoms related to dry mouth. A multi-centre study.. Swedish dental journal. 1990. 14. 4. 153–61. 2147787.
  19. Web site: Cochrane Database of Systematic Reviews. Riley. Philip. Glenny. Anne-Marie. Hua. Fang. Worthington. Helen V. 2017-07-31. John Wiley & Sons, Ltd. en. 10.1002/14651858.cd012744/full.
  20. Furness. Susan. Bryan. Gemma. McMillan. Roddy. Birchenough. Sarah. Worthington. Helen V.. 5 September 2013. Interventions for the management of dry mouth: non-pharmacological interventions. The Cochrane Database of Systematic Reviews. 9. CD009603. 10.1002/14651858.CD009603.pub3. 1469-493X. 24006231.
  21. Furness. S. Worthington, HV. Bryan, G. Birchenough, S. McMillan, R. Interventions for the management of dry mouth: topical therapies. Cochrane Database of Systematic Reviews. 7 December 2011. 12. CD008934. 10.1002/14651858.CD008934.pub2. 22161442. Furness. Susan.
  22. Iorgulescu. G. Saliva between normal and pathological. Important factors in determining systemic and oral health. Journal of medicine and life. Jul–Sep 2009. 2. 3. 303–7. 20112475. 5052503.