ISSN 0975-8437 INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(2):58-61

INTERNATIONALJOURNALOF DENTAL CLINICS VOLUME 3 ISSUE 2APRIL-JUNE 2011 58

Xerostomia: An overview
Nishat Sultana, M. Ehtaih Sham
Abstract
Xerostomia is a subjective sensation of a dry mouth which is a common complaint 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 common complaint found often
among older adults, affecting approximately 20 %
of the elderly. (2-4) The dry mouth is common
during periods of anxiety, 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.

Iat rogenic
Drugs
Local radiat ion
Chemot herapy
Chronic graft-versus-host disease
Diseases of t he salivary glands
Sjogrens syndrome
Sarcoidosis
HIV disease
Hepat itis C virus infection
Primary biliary cirrhosis
Cyst ic fibrosis
Diabet es mellit us
Rare causes
Amyloidosis
Hemochromatosis
Wegeners disease
Salivary gland agenesis (with or without
ect odermal dysplasia)
Triple A syndrome
Ot hers
Table 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
medications. 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
xerogenic drugs.(6) The drugs causing Xerostomia
was tabulated in table 2.

Drugs which direct ly damage t he salivary glands
Cyt ot oxic drugs
Drugs wit h ant icholinergic act ivity
Ant icholinergic agents: Atropine and Hyoscine
Ant i-reflux agents: Omeprazole
Psychoactive agents: Amitriptyline, Dothiepin
Select ive serot onin re-uptake inhibitors
Fluoxet ine
Ot hers: Phenothiazines, Benzodiazepines,
Opioids, Ant ihistamines
Drugs act ing on sympathetic syst em
Drugs wit h sympathomimetic activity
Ephedrine
Ant i-hypertensive:
Alpha 1 ant agonists: Terazosin, Prazosin
Alpha 2 agonist s: Clonidine
Bet a blockers: Atenolol, Propranolol
Drugs which deplet e fluid: Diuret ics.
Table 2: Drugs associat ed wit h dry mout h (5)

Xerostomia is a common side effect of
radiation therapy, when employed as primary,
concomitant or adjuvant treatment for primary or
recurrent tumors of head and neck. (5) The most
radiosensitive salivary gland is parotid gland
followed by submandibular, sublingual and minor
salivary gland. A radiat ion dose as low as 20 Gy
can cause permanent cessation of salivary flow if
given as a single dose. At doses above 52 Gy,
salivary dysfunction is severe. Treatment of oral
carcinoma 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 radiation, 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 radiation induce hypo salivation was
REVIEW ARTICLE
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INTERNATIONALJOURNALOF DENTAL CLINICS VOLUME 3 ISSUE 2APRIL-JUNE 2011 59
noted with the use of the radio-protective agent
amifostine which provides cyto-protection to
salivary glands.(7, 8)
Xerostomia is a well-known complicat 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 composition of saliva (i.e., a reduced
sodium Na
_
and raised K
_
ion concentration). The
squamous epithelium of the oral mucosa and the
epithelium 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.
Stimulated parotid flow rates are observed to be the
lowest in patients with poorly controlled diabetes
mellitus as compared to well controlled diabetes
mellitus. Approximately 24 to 48 percent of
diabetes mellitus patients have experienced parotid
gland enlargement. Diabetic patients are also
predisposed to develop oral candidiasis, median
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
multisystem immune-mediated disorder
characterized by inflammation of exocrine glands
leading to clinical symptoms of dryness,
particularly of the eyes and mouth, which can be
severe and disabling.(5, 11) Primary Sjogrens
syndrome presents in patients that do not suffer
from 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 Sarcoidosis 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)
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 lymphoma and intra
glandular lymphadenopathy; 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 fact ors for Xerost omia(5)
1. AIDS
2. Syst emic Lupus Eryt hematosus
3. Thyroid Dysfunction
4. Parkinsons Disease
5. Cerebral Palsy
6. Depression
7. Anxiet y
8. Post -Traumatic St ress Disorder
9. Dehydrat ion
10. Eat en-Lambert Syndrome
11. Trauma t o Salivary Glands
12. Anorexia and Bulimia
Table 3

The dental management of patients suffering
from dry 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 symptomatic relief, as well as preventing and
treating oral complicat 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 stimulate salivation. Consequently,
patients should be referred for nutritional
counseling to educate them to minimize any
negative effects from reactionary diet
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 symptoms in
patients with residual salivary capacity.(17) In
studies it has been found that xylitol sweetened
gums prevent caries development due to limited
ability of streptococcus mutants to ferment
xylitol.(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 from dry mouth to control and
prevent dental caries include adhering to a rigorous
oral hygiene regimen and non-cariogenic diet. The
need for meticulous 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 low abrasive, highly fluorinated
toothpaste is recommended, accompanied 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 available to stimulate 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 leading 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 approximately 3 to
6 tablets a day, not to exceeds two tablets per dose.
Side effects seen in radiation 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. Recommended
dosage for Cevimeline 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 affinity for the M3
muscarinic receptor subtypes found on salivary and
sweat gland. However its use in asthma patients or
those suffering from narrow angle glaucoma 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 flow 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
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 combination 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 of a
medication, an alternative medication that does not
employ 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
allow sufficient salivary flow during the eating
process, counteracting the drying effect of these
medications, 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
moisture 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, stimulating salivary flow 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 symptoms refractory to
pilocarpine therapy. (23)
A wide range of systemic therapies have been
advocated for the management of long-standing
xerostomia. At present, the anticholinergic agents
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INTERNATIONALJOURNALOF DENTAL CLINICS VOLUME 3 ISSUE 2APRIL-JUNE 2011 61
would seem to hold promise and are appropriate
for the treat ment of xerostomia associated with
radiation and Sjogrens syndrome. Future treat ment
for some 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, MDS, Assistant
Professor, Dept. of Oral Medicine and Radiology, 2. Dr.
M.E. Sham, MD, MDS Professor, Dept. Of Oral &
Maxillofacial Surgery, Videhi Institute of Medical
and Dental Sciences, White Field, Bangalore, India.
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Address for Correspondence
Dr. Nishat.S, MDS,
Asst. Prof., Dept. of Oral Medicine & Radiology,
Vydehi Institute of Dental Sciences,
White Field, Bangalore, India.
Email:nishat_tamanna9@rediffmail.com

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