Xerostomia

Background

• Xerostomia is a subjective sensation of dryness in the oral cavity, often due to a lack of or insufficient saliva secretion (hyposalivation).
• Usually affects patients aged > 65 years old, especially women in menopause, but can occur in younger patients.
• Conditions commonly associated with xerostomia include local factors (such as smoking or radiation therapy to head and neck), medication-induced dry mouth, and systemic conditions (such as Sjogren syndrome).

Evaluation

• Most patients report discomfort due to oral dryness as the first and most common symptom of xerostomia. Other symptoms may include
  • dysgeusia with a predominance of bitter and salty taste
  • burning of the tongue and/or lips (burning mouth syndrome)
• Xerostomia is typically diagnosed clinically with comprehensive history and oral exam (intra- and extraoral) that demonstrates clinical signs of hyposalivation and xerostomia.
• Inspect and palpate major salivary glands to identify masses, swelling, or tenderness.
• Consider sialometric testing to further inform diagnosis.
  • Very low salivary flow rates (< 0.1 mL/minute for unstimulated flow, < 0.7 mL/minute for stimulated flow) are associated with xerostomia.
  • Evaluation of the salivary flow rate can be used to set a baseline and monitor salivary gland function, but does not help diagnose underlying cause.
• Additional testing to identify underlying cause of xerostomia may include:
  • blood tests when xerostomia is suspected to be associated with a systemic disease
  • minor salivary gland biopsy to identify pathological changes associated with salivary gland dysfunction (histologic changes are one of the criteria used in the diagnosis of Sjogren syndrome)
  • biochemical analysis of saliva
  • sialography
  • scintigraphy with technetium-99m (99mTc)
  • computed tomography scans or magnetic resonance imaging of the salivary glands

Management

• Goal of treatment is to alleviate symptoms and prevent and correct potential complications, as well as treat any associated systemic diseases.
• General treatment strategies include:
  • patient education on proper oral hygiene and other interventions to help prevent and treat mouth dryness
  • management of systemic conditions and medications in consultation with the patient’s other healthcare providers, including
    • discontinuing or modifying the dose of any offending medications (if possible)
    • treatment of any underlying candidiasis
  • pharmacological treatment with salivary stimulants (sialagogues); commonly used options for patients with Sjogren syndrome or radiation therapy include
    • pilocarpine
      • suggested dose 5 mg 4 times daily
      • adverse effects may include sweating, nausea, and rhinitis
    • cevimeline
      • suggested dose 30 mg 3 times daily
      • has fewer cholinergic side effects than pilocarpine (such as sweating and gastrointestinal upset), and not associated with bradycardia
  • for patients who cannot tolerate sialagogues, palliative measures to improve salivary output, such as use of sugar-free salivary stimulants (chewing gum)
  • salivary substitutes to lubricate the oral mucosal tissue, relieve symptoms of xerostomia, and protect the teeth from demineralization
  • preventive measures to reduce oral disease and associated complications, which may require frequent dental care visits (usually every 3-6 months)
• Acupuncture might improve symptoms of dry mouth in patients with xerostomia following radiation therapy.