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REVIEW ARTICLE

Xerostomia: An overview
Nishat S ultana, M. Ehtaih S ham

Abstract
Xerostomia is a subjective sensation of a dry mouth which is a co mmon co mplaint among older
patients during period of anxiety, radiation therapy, immunological disorder which lead to increased frequency
of caries, candida infection, dysarthria and dysphagia. This article presents an overview of the Xerostomia and
its management.
Key Words: Xerostomia; Sjogrens syndrome; Radiation therapy
Received on: 13/08/2010 Accepted on: 13/11/2010
Xerostomia refers to a subjective sensation
of dry mouth; it is frequently, but not always,
associated with salivary gland hypo function.(1)
Xerostomia is a co mmon co mplaint found often
among older adults, affecting appro ximately 20 %
of the elderly.(2-4) The dry mouth is common
during periods of an xiety, mouth breathing and
with advancing age. Very rarely, children are born
with missing salivary glands so-called salivary
gland aplasia or agenesis. The table 1 shows the
common causes of dry mouth.
Iatrogenic
Drugs
Local radiation
Chemotherapy
Chronic graft-versus-host disease
Diseases of the salivary glands
Sjogrens syndrome
Sarcoidosis
HIV disease
Hepatitis C virus infection
Primary biliary cirrhosis
Cystic fibrosis
Diabetes mellitus
Rare causes
Amyloidosis
Hemochromatosis
Wegeners disease
Salivary gland agenesis (with or without
ectodermal dysplasia)
T riple A syndrome
Others
T able 1:Common causes of Xerostomia (5)

Xerostomia is the most common adverse

drug-related effect in the oral cavity. To date,
xerostomia has been associated with more than 500
med ications. Medications cause xerostomia by
interfering with the transmission of signals at the
parasympathetic
neuro
effector
junctions,
interfering with act ions at the adrenergic neuro
effector junctions, or causing the depression of the
connections of the autonomic nervous system.
Therapeutic doses of medications do not damage
salivary gland anatomy and any damage is
therefore reversible with discontinued use of

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xerogenic drugs.(6) The drugs causing Xerostomia

was tabulated in table 2.
Drugs which directly damage the salivary glands
Cytotoxic drugs
Drugs with anticholinergic activity
Anticholinergic agents: Atropine and Hyoscine
Anti-reflux agents: Omeprazole
Psychoactive agents: Amitriptyline, Dothiepin
Selective serotonin re-uptake inhibitors
Fluoxetine
Others: Phenothiazines, Benzodiazepines,
Opioids, Antihistamines
Drugs acting on sympathetic system
Drugs with sympathomimetic activity
Ephedrine
Anti-hypertensive:
Alpha 1 antagonists: Terazosin, Prazosin
Alpha 2 agonists: Clonidine
Beta blockers: Atenolol, Propranolol
Drugs which deplete fluid: Diuretics.
T able 2: Drugs associated with dry mouth (5)

Xerostomia is a common side effect of

radiation therapy, when emp loyed as primary,
concomitant or ad juvant treatment for primary or
recurrent tumors of head and neck. (5) The most
radiosensitive salivary gland is parotid g land
followed by submandibular, sublingual and minor
salivary gland. A radiat ion dose as low as 20 Gy
can cause permanent cessation of salivary flo w if
given as a single dose. At doses above 52 Gy,
salivary dysfunction is severe. Treatment of o ral
carcino ma
conventionally
involves
the
administration of a dose of 60 Gy to 70 Gy, and
this can lead to a rapid decrease in flow during the
first week of rad iation, with an eventual reduction
of 95%in the region. By 5 weeks of radiation, the
flow virtually ceases and rarely recovers
completely.(5) The degree of xerostomia depends
on the degree of exposure of the salivary tissue to
the radiation. To spare salivary function and
improve quality of life, salivary gland exposure to
radiation can be minimized by utilizing intensity
modulated radiat ion therapy and three dimensional
treatment planning and dose delivery techniques. A
reduction in rad iation induce hypo salivation was

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noted with the use of the radio-protective agent

amifostine wh ich provides cyto-protection to
salivary glands.(7, 8)
Xerostomia is a well-known comp licat ion of
chronic graft-versus host disease (cGVHD). A
prolonged significant reduction in parotid salivary
flow rate correlates with the histopathology
findings (ie, fibrosis of glands) and alterat ions in
the chemical co mposition of saliva (i.e., a reduced
sodium Na _ and raised K_ ion concentration). The
squamous epithelium of the oral mucosa and the
epitheliu m of salivary glands are affected early in
the course of cGVHD but the major salivary
functional injury in cGVHD occurs later, with the
target of destruction possibly being the muscarinic
receptor, water transporter or calcium ions.(9)
Levels of diabetes associated xerostomia are
reported in upwards of 40 to 80 percent of patients.
Stimu lated parotid flow rates are observed to be the
lowest in patients with poorly controlled d iabetes
mellitus as compared to well controlled d iabetes
mellitus. Approximately 24 to 48 pe rcent of
diabetes mellitus patients have experienced parotid
gland enlargement. Diabetic patients are also
predisposed to develop oral candidiasis, med ian
rhomboid glossitis, denture stomatitis and angular
chelitis associated with denture use and poor
glycemic control.it is believed that patient
xerostomia is one possible cause for this
predisposition.(10)
Sjogrens syndrome (SS) is a chronic
mu ltisystem
immune-mediated
disorder
characterized by inflammation of exocrine g lands
leading to clinical sympto ms of dryness,
particularly of the eyes and mouth, wh ich can be
severe and disabling.(5, 11) Primary Sjogrens
syndrome presents in patients that do not suffer
fro m another autoimmune disease, arthritic
symptoms or degenerative connective tissue
disease. Secondary Sjogrens syndrome present
alongside a second autoimmune disorder such as
systemic lupus erythematosus (SLE), Rheumatoid
Arthritis (RA), Scleroderma, mixed connective
disease, relapsing polychronditis and polymyositis.
Both primary and secondary forms are responsible
for mouth dryness and eye dryness.
Chronic Sarco idosis can give rise to
xerostomia and salivary gland enlargement in up to
9% of affected patients, often occurring as part of
Heerfordts syndrome.(12) In a study, the degree of
xerostomia and xerophthalmia were similar among
a group of patients with Sjogrens syndrome and a
group with Sarcoidosis, whereas parotid gland
enlargement was more frequently found in those
with Sarcoidosis.(13)

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Salivary gland disease can arise in 4% to 8%

of adults and children with HIV infection. The
principal clinical features of salivary gland disease
in HIV infection are as follow: a) associated
xerostomia and salivary gland enlargement, b)
Kaposis sarcoma causing salivary gland
enlargement, c) nonHodgkins lympho ma and intra
glandular
ly mphadenopathy; and d) acute
supportive sialadenitis.(14)
A number of addit ional disease entities may
contribute to the presence of xerostomia, either
through pathophysiology of the disease process or
due to the medications used in treating the disease
and its symptoms.(15) Patients with the following
disorders should be considered at risk for
xerostomia Table 3.
Risk factors for Xerostomia(5)
1. AIDS
2. Systemic Lupus Erythematosus
3. T hyroid Dysfunction
4. Parkinsons Disease
5. Cerebral Palsy
6. Depression
7. Anxiety
8. Post-Traumatic Stress Disorder
9. Dehydration
10. Eaten-Lambert Syndrome
11. T rauma to Salivary Glands
12. Anorexia and Bulimia
T able 3

The dental management of patients suffering

fro m d ry mouth should begin with thorough patient
education and the identification of the underlying
cause. Treatment should include local and systemic
stimulat ion of salivary glands, palliative treat ment
for sympto matic relief, as well as preventing and
treating oral co mp licat ions.(7) Patients with dry
mouth may stop chewing and reactively modify
their diet to a liquid or semi liquid diet rich in
fermentable carbohydrates in order to compensate
for oral dryness. Decreased
mastication
exacerbates the condition due to the fact that
periodontal mechanoreceptors and mechanical
stimulat ion of the oral mucosa and tongue are
required stimu late salivation. Consequently,
patients should be referred for nutritional
counseling to educate them to min imize any
negative
effects
from
reactionary
d iet
alterations.(16)
A non-specific mechanical and gustatory
stimulant increases salivation; therefore, the use of
sugar free gums, hard candies, and mints are highly
recommended for the relief of sympto ms in
patients with residual salivary capacity.(17) In
studies it has been found that xylitol sweetened
gums prevent caries develop ment due to limited
ability of streptococcus mutants to ferment
xy litol.(18) The use of citric acid or candies is

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discouraged
due
to
accelerating
caries
development.(16) Lifestyle changes available to
patients suffering fro m dry mouth to control and
prevent dental caries include adhering to a rigorous
oral hygiene regimen and non-cariogenic diet. The
need for meticu lous plaque control via assiduous
oral hygiene is necessary for xerostomic patients.
Brushing twice a day with a soft bristle toothbrush
and the use of a lo w abrasive, highly fluorinated
toothpaste is reco mmended, acco mpanied by a
sodium fluoride rinse.(19) Current interest involves
the use of fluoride varnishes to prolong the
exposure to fluoride an approach that may be
beneficial to prevent xerostomia associated
caries.(7)
Medications are availab le to stimu late the
salivation. Prescribing parasympathetic drugs like
pilocarpine has been approved for xerostomia
patients. Pilocarpine is a potent and naturally
occurring nonspecific cholinergic agonist which
stimulates muscarinic receptor lead ing to the
secretion of water and electrolytes, if the patients
has sufficient amount of functional salivary gland
tissue. Pilocarpine has also shown to be effective in
patients who have undergone radiation therapy or
bone marrow transplantation. Initial dose of
pilocarpine should be administered 30 minutes
before meals, in 5 mg tablets 3 to 4 t imes a day,
with the usual dose range being appro ximately 3 to
6 tablets a day, not to exceeds two tablets per dose.
Side effects seen in rad iation induced xerostomia
patients include sweating, chills, nausea, dizziness,
rhinit is and asthenia 5. New modes of delivery are
also
being researched
including
loading
nanoparticles with pilocarpine.(20)
Cevimeline is another cholinergic agonist
used to induce salivary function. Reco mmended
dosage for Cev imeline is 30 mg, 3 times a day. It is
capable of inducing salivation with minimal
adverse cardiac and pulmonary effects due to the
fact that Cevimeline has a high affin ity for the M3
muscarin ic receptor subtypes found on salivary and
sweat gland. However its use in asthma patients or
those suffering fro m narrow angle glauco ma is
questionable. Animal studies have shown that
Cevimeline has adverse effects on the fetus but its
use during pregnancy is considered acceptable if
the benefits are considered acceptable.(7, 21)
Bethanecol found to increase the stimulated
and unstimulated salivary flo w rates of patients
with xerostomia secondary to radiation, but
objective changes in salivary flow rates did not
always correlate with symptomat ic improvement. It
is given in a dose of 25 mg; 3 times daily
orally.(20)
Anethole trithione is specifically
used to treat Sjogrens associated xerostomia. It

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increases the number of receptor sites on the

salivary acinar cells. Patients benefits have been
reported
when
Sjogrens
patients
were
administered 25mg doses 3 times a day. A
synergistic effect on salivation has been observed
when a co mbination of pilocarpine and anethole
trithione has been administered.(22)
When a patient complaints of xerostomia
and is believed or diagnosed to be a side effect o f a
med ication, an alternative medication that does not
emp loy the same mode of action may be
prescribed. The dentist should consult the patients
physician and pharmacist if an eliminat ion or
change of medicat ion is being contemplated.
Patients are urged to coordinate the timing of the
dose of necessary medications with meal times to
allo w sufficient salivary flo w during the eating
process, counteracting the drying effect of these
med ications, due to the fact that salivary flow is
lowest during sleep the patient should avoid taking
medications before bedtime.(16)
Patients affected with xerostomia should
also increase their fluid intake due to the fact that
most people do not drink enough water,
contributing to the condition.(16) The patients
should be encouraged to place ice chips in their
mouth and sip water throughout the day to provide
mo isture and possibly provide relief to dry mouth
symptoms.(7).
For patients with ext remely low salivary
flow rates, the use of saliva substitute based on
polyacrylic acid and Xanthan gum has been
developed and are recommended.(17) Ideal
characterizat ion of saliva substitute is that, it
should be long lasting, provides lubrication to
protect oral tissues as well as impedes the
colonizat ion and action of cariogenic bacteria, has
not been developed.(16) Salivary substitute tend to
be short acting, providing relief for a limited period
of time . They are most effective when applied
before sleeping or speaking.(7)
Acupuncture has been reported to increase
parasympathetic activity, causing a release in
neuropeptide, stimu lating salivary flo w and
secretions. Three points are t reated in each ear, and
one in the radial aspect of each index finger.(23) A
regimen of three to four weekly treat ments
followed
by
monthly
sessions
is
now
recommended, although some patients achieve
lasting response without further therapy.
Preliminary data revealed that many patients
achieve relief, even for sympto ms refractory to
pilocarpine therapy. (23)
A wide range of systemic therapies have been
advocated for the management of long-standing
xerostomia . At present, the anticholinerg ic agents

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would seem to hold promise and are appropriate

for the treat ment of xerostomia associated with
radiation and Sjogrens syndrome. Future treat ment
for so me of the salivary gland disorders may
require the use of gene therapy and tissue
engineering, but at present there is a need to have a
greater understanding of the causes and
pathogenesis of salivary gland disease before
specific therapies can be developed.
Authors Affiliations: 1. Dr. Nishant. S, M DS, Assistant
Professor, Dept. of Oral M edicine and Radiology, 2. Dr.
M .E. Sham, M D, M DS Professor, Dept. Of Oral &
M axillofacial Surgery, Videhi Institute of M edical
and Dental Sciences, White Field, Bangalore, India.
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Address for Correspondence
Dr. Nishat.S, M DS,
Asst. Prof., Dept. of Oral M edicine & Radiology ,
Vydehi Institute of Dental Sciences,
White Field, Bangalore, India.
Email:nishat_tamanna9@rediffmail.com

Source of Support: Nil, Conflict of Interest: None Declared

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