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BackTable / ENT / Article
Xerostomia Causes, Symptoms & Treatment: Not Such a Dry Topic
Julia Casazza • Updated Jun 18, 2024 • 34 hits
Xerostomia is a dry mouth sensation due to insufficient saliva. At first thought, this may seem trivial, but insufficient saliva can cause bad breath, difficulty chewing, difficulty swallowing, and cavity formation. The diagnosis of xerostomia is clinical. Management of the condition focuses on mitigating symptoms and increasing saliva production. Join BackTable ENT as we explore xerostomia treatment with dentists Dr. Anuskha Gaglani and Dr. Abhishek Nagaraj of Areo Dental Group.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Xerostomia differs from a general dry mouth sensation in that xerostomia is specifically caused by insufficient saliva production.
• Lifestyle modifications such as sleeping with one’s mouth closed, drinking more water, or drinking less caffeine, may suffice to treat xerostomia in select patients.
• Physical exam findings in patients with xerostomia include reduced saliva, angular cheilitis, and tongue fissures.
• Treatment of xerostomia includes symptomatic and medical management. Medications used to increase saliva production act by increasing acetylcholine activity.
• Xerostomia patients benefit from meticulous dental hygiene and frequent dental cleanings (i.e. four times yearly) to counter their increased likelihood of cavity formation.
Table of Contents
(1) Evaluating Xerostomia
(2) Xerostomia Causes
(3) Xerostomia Treatment: Symptomatic & Medical Management
(4) Dental Needs of the Xerostomia Patient
Evaluating Xerostomia
First and foremost, patients with xerostomia complain of dry mouth. Depending on the extent of the dryness, they may experience difficulty chewing, difficulty swallowing, and bad breath. When taking a history, focus on medication use, caffeine consumption, and alcohol consumption, as these can cause or exacerbate xerostomia. On physical exam, patients will have reduced saliva (which can be measured using the salivary flow test) that is thick and stringy in character. They may also have numerous dental caries, angular cheilitis, and tongue fissures.
[Dr. Gopi Shah]
Today, we're going to talk about xerostomia, dry mouth. How do these patients present to you? Is there a common age or risk factor that you've noticed in your practice?
[Dr. Anushka Gaglani]
Yes. There's so many ways that they can present to us. We have patients who come in at any age really. More likely, it's patients who are older. I think the statistic is that 30% of patients over the age of 65 and 40% of patients over the age of 80 usually have xerostomia. It's usually due to medications. Usually, it's for more medications that really increase that risk, but also comorbid conditions like diabetes, Alzheimer's, Parkinson's, et cetera.
There's such limited data on xerostomia. It's anywhere between 0.9% to 64.8% of the population who suffers from it, which is such a wide range. In our experience, it's definitely though, again, those older patients or lifestyle factors, which we'll obviously dig deeper into.
…
[Dr. Anushka Gaglani]
Yes. We'll talk about their lifestyle factors like we mentioned earlier. Are they staying hydrated? Are they keeping their oral hygiene up to par? Are they alcohol users? Do they smoke? Do they drink a lot of caffeine? All of these are going to be lifestyle factors. We also will look at any medications. I mentioned earlier, comorbid factors. Medications like antihistamines, antihypertensive, decongestants, pain meds, diuretics, antidepressants, these are going to be those bigger risk factors. We'll look for those things first.
A lot of people will think that they have dry mouth, but really they don't. What we do is we check for any salivary pooling on the floor of the mouth. There is a salivary flow rate test that can be done as well. What we check for is either reduced unstimulated flow, which has to be, I believe it's 0.1 milliliters per minute of flow. That's measured over a 5 to 15-minute period. In chewing, it has to be at least 0.7 milliliters per minute or more to not have reduced salivary flow. That's checked over five minutes.
The last thing we would do really, if we see that someone is not pulling saliva or if they have reduced salivary flow, we can actually also do a minor salivary gland biopsy. By we, I don't mean the general dentists. We would refer out to an oral surgeon, oral medicine practitioner, or an ENT in that case.
[Dr. Abhishek Nagaraj]
Those are great points. Generally, people with dry mouth or xerostomia will present with thick, stringy saliva. That's usually generally a really good sign. That's where we start to decipher whether it's really lifestyle-related or dig deeper. They will also present with a lot of dental caries, rampant caries. We could be doing a bunch of work on them. Six months later, they have this whole mouth full of new cavities as though we never saw.
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Xerostomia Causes
Both lifestyle and medications affect salivary production. Lifestyle factors include insufficient water consumption, mouth breathing, and excessive caffeine consumption. Medical causes include prior radiation to salivary glands, chemotherapy, autoimmune disease (such as Sjogren’s syndrome), and medications. The most common medications that interfere with salivary production include antihistamines, antihypertensives, decongestants, pain medications, diuretics, and antidepressants. The risk for xerostomia increases as the number of culprit medications taken increases.
[Dr. Gopi Shah]
In terms of medications, initially, you had mentioned four or more medications. Is it four or more of the medications that have the side effects of dry mouth or is that what you had meant with that?
[Dr. Anushka Gaglani]
It's a combination of medications of really any four medications that can cause that, but it's obviously intensified with those particular ones that are related to dry mouth.
[Dr. Abhishek Nagaraj]
I think standalone can do it too. A standalone Lisinopril for hypertensives has one of the side effects as dry mouth. Just combination drug therapy just exacerbates that condition.
[Dr. Ashley Agan]
You ask about the different lifestyle things, are you drinking enough water, are you a mouth breather, are you drinking a lot of coffee, those types of things. Then you're looking at their medication lists, and then let's say you mark off, okay, this could be causing it, this could be causing it. You're going down. Then any other types of screening questions when it comes to the other types of things that can cause dry mouth. Thinking of things like Sjogren's or history of radiation or other types of things that don't fit into the other boxes.
[Dr. Anushka Gaglani]
Yes, for sure. We're looking at chemo as well. We're looking at radiation. We're looking at autoimmune diseases. You mentioned Sjogren's disease, that definitely plays a big role. Lacrimal ducts as well. Then radioactive iodine. If anyone's gone through thyroid treatment, that's something else we would ask about because that does affect it. Especially the parotid gland is where it would affect it. That's going to be the major salivary producer.
[Dr. Abhishek Nagaraj]
Right. Ashley, I'm glad you bring that up because I think the first two lines of questioning with the lifestyle and the medication stuff, most people will fall in those two. It's that third line of questioning, which is then like, hey, have any recent history of radiation treatment or Sjogren's, because generally, that has some dry eyes type symptoms too. That would be our third line of questioning for sure.
Xerostomia Treatment: Symptomatic & Medical Management
Management of xerostomia consists of symptomatic treatment and medications that stimulate saliva production. Symptomatic treatment includes mouthwashes, lozenges, and sugar-free gum. Particularly effective are products containing xylitol, which triggers salivation, and sodium benzoate, which increases salivary foaminess to assist with swallowing. Medications used for xerostomia stimulate acetylcholine activity, which increases salivary production. The two drugs most commonly used include pilocarpine (dosed at 5 mg three times per day) and cevimeline hydrochloride (dosed at 30 mg daily).
[Dr. Ashley Agan]
Once you've determined-- let's say we're going to focus on the patient who truly does have xerostomia and not necessarily the patient who has that sensation of dry mouth, because that's opening up a whole other conversation, so patients who we've determined truly have xerostomia, they're not making enough saliva, how do you start to treat that?
Especially when you have patients who are on a lot of medications that you maybe can't tinker with or mess with. You can't say like, "Okay, well, let's just stop all your medications because we want your saliva to come back." I feel like that's one of the hardest things that I deal with. It's trying to decide, is it the medication and how do we treat this? Some patients will say, "Well, I've been on this medication for 15 years, and now I'm having dry mouth. It's probably not the medication, right?"
[Dr. Abhishek Nagaraj]
It's tough. Navigating that is hard. Two lines of treatment. One is obviously symptomatic. How do we get people to feel better and manage their symptoms? That would be palliative. Things like ACT lozenges, Biotène lozenges, mouthwash, generally these mouthwashes have xylitol in them and they also have some sodium monophosphate, I want to say, and then sodium benzoates that make it generally easier for them to swish and make it really foamy for patients. That would be palliative.
[Dr. Anushka Gaglani]
Those sugar-free gums, candies, avoiding salty, spicy, dry, sticky, sugary foods because obviously, with less saliva as a buffer, they're more prone to the caries. Avoiding irritants like alcohol,-
[Dr. Abhishek Nagaraj]
Caffeine.
[Dr. Anushka Gaglani]
-mouth rinses, tobacco, caffeine. Those are going to be more on the palliative side. Then, of course, there's the medication side.
[Dr. Abhishek Nagaraj]
On the medication side, inducing saliva because obviously, a lot of these patients who suffer from xerostomia have anticholinergic drugs that are interacting with their acetylcholine receptors. We want to get acetylcholine inducers like pilocarpine. Pilocarpine, cevimeline is another one that's being—
[Dr. Anushka Gaglani]
Hydrochloride.
[Dr. Abhishek Nagaraj]
Hydrochloride that's being used to induce some salivary flow. Sugar-free lozenges, obviously, is a common go-to for most patients, but those are the more extreme cases, and especially people with sugar-induced disease or autoimmune conditions.
Dental Needs of the Xerostomia Patient
Cavities more easily develop in a mouth with less saliva, so xerostomia patients need strategies to aggressively fight tooth decay. These strategies include cleanings, dental hygiene, and fluoride treatment. Ensuring patients have a general dentist that they see routinely is essential. Patients with xerostomia need cleanings four times yearly. From a personal hygiene standpoint, patients should brush their teeth at least two (ideally three) times a day and floss four to five times weekly. One helpful adjunct to this hygiene strategy is fluorination treatments to increase tooth strength. Prescription-strength gels and toothpastes (such as Prevident 5000) contain the level of fluoride needed for best results.
[Dr. Ashley Agan]
Yes, I think it can be really challenging, especially because some patients will have multiple reasons to have dry mouth. You're going through the list and they check off some of the boxes for the lifestyle, they check off some of the boxes for the medication. You're thinking, well, what angle are we going to use to try to treat this and make it better? I think we, at least in my world with general ENT, sometimes I forget about the complications when it comes to dental hygiene with having dry mouth because when patients are using these lubricants to help with the symptoms, I assume that doesn't actually help with the prevention of caries though, does it, because it's not actually saliva? How does that work out?
[Dr. Anushka Gaglani]
To some extent, it may because it does have calcium phosphate ions in it and that helps remineralize. To some extent, yes, it will. It will act as a buffer as well. Again, it's more topical. It's unfortunately not going to be systemic.
[Dr. Abhishek Nagaraj]
The Biotène mouthwashes have some fluoride in them. They're sodium fluorides. Those are really-- I wouldn't say they're really effective. They're somewhat effective.
[Dr. Anushka Gaglani]
Yes. I was going to say the fluoride is really a big piece to that. A lot of these artificial salivas don't have that. If it's possible, I would definitely recommend that along with a fluoride gel, just going back to the importance of fluoride, fluoride gel and even making sure we're getting that systemic fluoride through fluoridated tap water.
Podcast Contributors
Dr. Anushka Gaglani
Dr. Anushka Gaglani is a practicing dentist in Chicago and the co-founder and co-CEO of Areo Dental Group..
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, April 6). Ep. 103 – Xerostomia: The Dentist's Perspective [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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