Xerostomia is defined as dry mouth resulting from reduced or absent saliva flow.

Xerostomia is
not a disease, but it may be a symptom of various medical conditions, a side effect of a radiation
to the head and neck, or a side effect of a wide variety of medications. It may or may not be
associated with decreased salivary gland function. Xerostomia is a common complaint found
often among older adults, affecting approximately 20 percent of the elderly. However, xerotomia
does not appear to be related to age itself as much as to the potential for elderly to be taking
medications that cause xerostomia as a side effect.

Normal salivary function is mediated by the muscarinic M3 receptor. Stimulation of this receptor
results in increased watery flow of salivary secretions. When the oral mucosal surface is
stimulated, afferent nerve signals travel to the salivatory nuclei in the medulla. The medullary
signal may also be affected by cortical inputs resulting from stimuli such as taste, smell, anxiety
or depression. Efferent nerve signals, mediated by acetylcholine, also stimulate salivary
glandular epithelial cells and increase salivary secretions.

Saliva components

Saliva is the viscous, clear, watery fluid secreted from the parotid, submaxillary, sublingual and
smaller mucous glands of the mouth. Saliva contains two major types of protein secretions, a
serous secretion containing the digestive enzyme ptyalin and a mucous secretion containing the
lubricating aid mucin. The pH of saliva falls between 6 and 7.4. Saliva also contains large
amounts of potassium and bicarbonate ions, and to a lesser extent sodium and chloride ions. In
addition, saliva contains several antimicrobial constituents, including thiocyanate, lysozyme,
immunoglobulins, lactoferrin and transferrin.

Functions of saliva

Saliva possesses many important functions including antimicrobial activity, mechanical

cleansing action, control of pH, removal of food debris from the oral cavity, lubrication of the
oral cavity, remineralization and maintaining the integrity of the oral mucosa.

Complications associated with xerostomia

Xerostomia is often a contributing factor for both minor and serious health problems. It can
affect nutrition and dental, as well as psychological, health. Some common problems associated
with xerostomia include a constant sore throat, burning sensation, difficulty speaking and
swallowing, hoarseness and/or dry nasal passages.1 Xerostomia is an original hidden cause of
gum disease and tooth loss in three out of every 10 adults.11 If left untreated, xerostomia
decreases the oral pH and significantly increases the development of plaque and dental
caries.Oral candidiasis is one of the most common oral infections seen in association with
xerostomia.

Signs and symptoms of xerostomia

Individuals with xerostomia often complain of problems with eating, speaking, swallowing and
wearing dentures. Dry, crumbly foods, such as cereals and crackers, may be particularly difficult
to chew and swallow. Denture wearers may have problems with denture retention, denture sores
and the tongue sticking to the palate. Patients with xerostomia often complain of taste disorders
(dysgeusia), a painful tongue (glossodynia) and an increased need to drink water, especially at
night. Xerostomia can lead to markedly increased dental caries, parotid gland enlargement,
inflammation and fissuring of the lips (cheilitis), inflammation or ulcers of the tongue and buccal
mucosa, oral candidiasis, salivary gland infection (sialadenitis), halitosis and cracking and
fissuring of the oral mucosa.

Diagnosis and evaluation of xerostomia

Diagnosis of xerostomia may be based on evidence obtained from the patient’s history, an
examination of the oral cavity and/or sialometry, a simple office procedure that measures the
flow rate of saliva. Xerostomia should be considered if the patient complains of dry mouth,
particularly at night, or of difficulty eating dry foods such as crackers. When the mouth is
examined, a tongue depressor may stick to the buccal mucosa. In women, the “lipstick sign,”
where lipstick adheres to the front teeth, may be a useful indicator of xerostomia.

The oral mucosa may be dry and sticky, or it may appear erythematous due to an overgrowth of
Candida albicans. The red patches often affect the hard or soft palate and dorsal surface of the
tongue. Occasionally, pseudomembranous candidiasis will be present, appearing as removable
white plaques on any mucosal surface. There may be little or no pooled saliva in the floor of the
mouth, and the tongue may appear dry with decreased numbers of papillae. The saliva may
appear stringy, ropy or foamy. Dental caries may be found at the cervical margin or neck of the
teeth, the incisal margins or the tips of the teeth.

Several office tests and techniques can be utilized to ascertain the function of salivary glands. In
sialometry, or salivary flow measurement, collection devices are placed over the parotid gland or
the submandibular/

sublingual gland duct orifices, and saliva is stimulated with citric acid. The normal salivary flow
rate for unstimulated saliva from the parotid gland is 0.4 to 1.5 mL/min/gland. The normal flow
rate for unstimulated, “resting” whole saliva is 0.3 to 0.5 mL/min; for stimulated saliva, 1 to 2
mL/min. Values less than 0.1 mL/min are typically considered xerostomic, although reduced
flow may not always be associated with complaints of dryness.

Sialography is an imaging technique that may be useful in identifying salivary gland stones and
masses. It involves the injection of radio-opaque media into the salivary glands. Salivary
scintigraphy can be useful in assessing salivary gland function. Technetium-99m sodium
pertechnate is intravenously injected to ascertain the rate and density of uptake and the time of
excretion in the mouth. Minor salivary gland biopsy is often used in the diagnosis of Sjögren’s
syndrome (SS), human immunodeficiency virus-salivary gland disease, sarcoidosis, amyloidosis
and graft-vs.-host disease. Biopsy of major salivary glands is an option when malignancy is
suspected.

Common causes of xerostomia

Medications
 Perhaps the most prevalent cause of xerostomia is medication. Xerogenic drugs can be found in
42 drug categories and 56 subcategories. More than 400 commonly used drugs can cause
xerostomia. The main culprits are antihistamines, antidepressants, anticholinergics, anorexiants,
antihypertensives, antipsychotics, anti-Parkinson agents, diuretics and sedatives. Other drug
classes that commonly cause xerostomia include antiemetics, antianxiety agents, decongestants,
analgesics, antidiarrheals, bronchodilators and skeletal muscle relaxants.It should be noted that,
while there are many drugs that affect the quantity and/or quality of saliva, these effects are
generally not permanent.

Patients complaining of xerostomia should be interviewed and their medications should be

reviewed. It may be possible to change medications or dosages to provide increased salivary
flow. Symptoms of xerostomia are often worse between meals, at night and in the morning.
Therefore, consider modifying drug schedules to achieve maximum plasma levels when the
patient is awake.9 Consider easy-to-take formulations, such as liquids, and avoid sublingual
dosage forms if possible. Counsel your patients regarding which medications can and cannot be
crushed. Also counsel them to first lubricate the mouth and throat with water prior to taking
capsules and tablets and to follow this with a full glass of water. If possible, consider switching
the patient from one medication to another with comparable efficacy but with less
anticholinergic activity, for example, switching from the tricyclic antidepressant amoxapine to
desipramine.

What is Sjögren's syndrome?

  Readers Comments 93

  Share Your Story

Sjögren's syndrome is an autoimmune disease characterized by dryness of the

mouth and eyes. Autoimmune diseases feature the abnormal production of extra
antibodies in the blood that are directed against various tissues of the body. The
misdirected immune system in autoimmunity tends to lead to inflammation of
tissues. This particular autoimmune illness features inflammation and dysfunction
in glands of the body that are responsible for producing tears and saliva.
Inflammation of the glands that produce tears (lacrimal glands) leads to
decreased water production for tears and dry eyes. Inflammation of the glands
that produce the saliva in the mouth (salivary glands, including the parotid
glands) leads to decreased saliva production and dry mouth and dry lips.
Sjögren's syndrome with gland inflammation (resulting in dry eyes and mouth,
etc.) that is not associated with another connective tissue disease is referred to
as primary Sjögren's syndrome. Sjögren's syndrome that is also associated with
a connective tissue disease, such as rheumatoid arthritis, systemic lupus
erythematosus, or scleroderma, is referred to as secondary Sjögren's syndrome.
Dryness of eyes and mouth, in patients with or without Sjögren's syndrome, is
sometimes referred to as sicca syndrome.

What causes Sjögren's syndrome?

While the exact cause of Sjögren's syndrome is not known, there is growing
scientific support for genetic (inherited) factors. The genetic background of
Sjögren's syndrome patients is an active area of research. The illness is
sometimes found in other family members. It is also found more commonly in
families that have members with other autoimmune illnesses, such as systemic
lupus erythematosus, autoimmune thyroid disease, type I diabetes, etc. Most
patients with Sjögren's syndrome are female.

What are risk factors for developing Sjögren's

syndrome?

The main risk factor for the development of Sjögren's syndrome is being a
member of a family that is already characterized as having autoimmune
illnesses. This does not mean that it is predictable that a member of a family with
known autoimmunity will develop the disease, only that is more likely than if there
were no family members with known autoimmunity. Accordingly, it is likely that
certain genes that are inherited from ancestors can predispose one to the
development of Sjögren's syndrome. It should also be noted that Sjögren's
syndrome can also be sporadic and occur in a person from a family with no
known autoimmunity.

Sialolithiasis (also termed salivary calculi,[1] or salivary stones),[1] is a condition where a calcified

mass or sialolith forms within a salivary gland, usually in the duct of the submandibular gland (also
termed "Wharton's duct"). Less commonly the parotid gland or rarely the sublingual gland or a minor
salivary gland may develop salivary stones.
The usual symptoms are pain and swelling of the affected salivary gland, both of which get worse
when salivary flow is stimulated, e.g. with the sight, thought, smell or taste of food, or with hunger or
chewing. This is often termed "mealtime syndrome".[2] Inflammation or infection of the gland may
develop as a result. Sialolithiasis may also develop because of the presence of existing chronic
infection of the glands, dehydration (e.g. use of phenothiazines), Sjögren's syndrome and/or
increased local levels of calcium, but in many instances the cause is idiopathic (unknown).
The condition is usually managed by removing the stone, and several different techniques are
available. Rarely, removal of the submandibular gland may become necessary in cases of recurrent
stone formation. Sialolithiasis is common, accounting for about 50% of all disease occurring in the
major salivary glands and causing symptoms in about 0.45% of the general population. Persons
aged 30–60 and males are more likely to develop sialolithiasis. [2]

Halitosis – or chronic bad breath – is something that mints, mouthwash or a good brushing can’t
solve. Unlike “morning breath” or a strong smell that lingers after a tuna sandwich, halitosis
remains for an extended amount of time and may be a sign of something more serious. 

What Causes Halitosis?

If quick bad breath fixes are only covering up the problem for a short time, something else may
be happening in your body, including: 

Dental Issues: Cavities and deeper pockets from gum disease give bad breath bacteria extra
places to hide in your mouth that are difficult to clear out when you’re brushing or cleaning
between your teeth. Either can contribute to halitosis.

Mouth, Nose and Throat Infections: According to the Mayo Clinic, nose, sinus and throat
issues that can lead to postnasal drip may also contribute to bad breath. Bacteria feeds on
mucus your body produces when it’s battling something like a sinus infection, leaving you sniffly
and stinky.

Dry mouth: Saliva goes a long way for your dental health – and your breath. It rinses and
removes unwanted leftovers from your mouth, helps break down food when you eat and
provides disease-fighting substances to help prevent cavities and infections. If you don’t make
enough saliva, one sign may be halitosis. Dry mouth can be caused by medications, certain
medical conditions, alcohol use, tobacco use or excessive caffeine. 

Smoking and tobacco: Tobacco products wreak havoc on your body and your breath. Not only
do many tobacco products leave their own odor on your breath; they can also dry out your
mouth. Smokers are also more likely to develop gum disease, which can also add to halitosis. 

Other chronic conditions: While halitosis is most often linked to something happening in your
mouth, it may also be a sign of gastric reflux, diabetes, liver or kidney disease. 

Handling Halitosis
If you notice your breath has been less than fresh lately, start by following a healthy daily dental
routine – brush twice a day for two minutes with a fluoride toothpaste and clean between your
teeth once a day. Other things, like drinking plenty of water, chewing sugarless gum with
the ADA Seal of Acceptance and cutting back on caffeine may also help get your saliva flowing
and boost the freshness of your breath.

If you notice your bad breath persists, check in with your dentist. Together, you can track down
what the cause may be. With a proper cleaning and exam, your dentist can help rule out any
oral health problems and advise you on next steps, including what types of dental products to
use, treatment plans to take care of cavities or gum disease or refer you to a medical provider to
follow up.

What causes tooth decay?

Bacteria and food can cause tooth decay. A clear, sticky

substance called plaque is always forming on your teeth
and gums. Plaque contains bacteria that feed on the
sugars in the food you eat.
As the bacteria feed, they make acids. The acids attack the
teeth for 20 minutes or more after you eat. Over time,
these acids destroy tooth enamel, causing tooth decay.
Things that make you more likely to have tooth decay
include:

 Not brushing and flossing your teeth regularly and not

seeing a dentist for checkups and cleanings.
 Eating foods that are high in sugar and other
carbohydrates, which feed the bacteria in your mouth.
 Not getting enough fluoride. Fluoride helps prevent
tooth decay by making teeth more resistant to acids
produced by plaque. Fluoride is added to many public
water supplies.
 Not having enough saliva. Saliva washes away food
and harmful sugars, so it helps protect your teeth
from decay. A dry mouth may be caused by a
condition such as xerostomia or Sjögren's syndrome,
by taking certain medicines, or by breathing through
your mouth. Older adults are more likely to have
a dry mouth.
 Having diabetes.
 Smoking, using spit (smokeless) tobacco, or
breathing secondhand smoke.

Children, whose teeth are still growing, are more likely

than adults to have tooth decay. This is because the
minerals in new teeth are not very strong and are easier
for acids to eat away.
Even babies can be at risk for tooth decay. Babies who are
put to bed with a bottle can get "bottle mouth  "-tooth
decay caused by the sugar in milk, formula, or juice.
Babies aren't born with decay-causing bacteria in their
mouths. But they can get bacteria from adults who share
spoons, forks, or other utensils with them.
What are the symptoms?

Tooth decay usually doesn't cause symptoms until you

have a cavity or an infected tooth. When this happens, you
may have:

 A toothache, which is the most common symptom.

 Swelling in your gums near a sore tooth. This can be a
sign of severe tooth decay or an abscessed tooth  .
 Bad breath or a bad taste in your mouth.
 White, gray, brown, or black spots on your teeth.

If you have a toothache, see a dentist. Sometimes the

pain will go away for a while, but the tooth decay will keep
growing. If you don't get treatment, your cavities could get
worse and your tooth could die.