FACT SHEET: Xerostomia (also known as “dry mouth” and “dry mouth syndrome”)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- No.
Is medical consult advised?
- Yes, if the xerostomia has not yet been assessed by a physician or dentist for definitive diagnosis and management (including potential prescription medication if intraoral infection is present).
Is the initiation of invasive dental hygiene procedures contra-indicated?**
- No.
Is medical consult advised?
- See above.
Is medical clearance required?
- No.
Is antibiotic prophylaxis required?
- No.
Is postponing treatment advised?
- No, unless an active intraoral infection (e.g., candidiasis) is suspected.
Oral management implications
- Although treatment depends on the cause, dry mouth is often a hyposalivation side effect of over-the-counter (OTC) or prescription medication. Xerostomia may improve with an adjusted dosage or alternative OTC or prescription medication. Patients/clients should consider discussing this with their pharmacist or prescribing physician, as appropriate.
- From a dietary perspective, caffeine is the most commonly identified contributor to xerostomia. Alcohol consumption is a common modifying factor.
- Other causes of acute or chronic reduced salivary flow include: mechanical blockage; dehydration; infection of the salivary glands; anemia; local surgery; damage to the innervation (nerves) of the salivary glands; connective tissue diseases (e.g., scleroderma); Sjögren syndrome; sarcoidosis; radiation therapy of the head or neck; chemotherapy; immunotherapy1; emotional stress; and congenital factors (e.g., ectodermal dysplasia). Xerostomia may also result from mouth breathing, snoring, and other diseases which cause hyposalivation and/or change in saliva consistency. Tobacco use (smoking or chewing tobacco), alcohol use, vaping (e-cigarettes), and recreational drug use (including methamphetamine and cannabis) can cause dry mouth. In some cases, there is no identifiable cause.
- Self-care steps to ease oral dryness include drinking plenty of water, letting ice melt in the mouth, chewing sugarless gum, sucking sugarless mints, restricting caffeine intake, humidifying the ambient environment, using lip balm, avoiding toothpaste containing sodium lauryl sulphate (which may be irritating), and avoiding tobacco, cannabis, and alcohol (including mouth rinses containing alcohol).
- Avoidance of excessive consumption of salty and spicy foods is often beneficial. Salty foods lead to thirst, and spicy foods have a diuretic effect.
- Sugary and acidic drinks should be avoided as much as possible by patients/clients with impaired salivary flow. This is because such beverages increase risk of caries even more in the absence of the buffering effects of saliva.
- Daily therapeutic doses of xylitol-containing mints and gums can be recommended to reduce Streptococcus mutans and stimulate saliva production. Relief of dry mouth and dry throat may also be obtained via the use of artificial saliva substitutes/oral moisturizers or by being prescribed cholinergic sialagogues (e.g., pilocarpine or cevimeline) that stimulate salivary flow. Saliva stimulators such as oral orthotics and electrostimulation devices2 may be options for some patients/clients.
- Supplemental daily fluoride and amorphous calcium phosphate therapy (i.e., remineralizing therapy) to reduce caries and dentinal hypersensitivity may be options for certain patients/clients with chronic xerostomia.
- Xerostomic patients/clients are at elevated risk of oral infections, including periodontitis, gingivitis, and viral and fungal infections. Consequently, there is benefit from the use of daily antimicrobial therapy, such as chlorhexidine and essential oil mouth rinses.
- Given the friability of their mucous membranes (due to decreased lubrication from salivary mucins), xerostomic patients/clients are highly susceptible to oral trauma from toothbrushing, mastication, and rubbing against appliances and dentures. The incidence and severity of associated aphthous ulcers can be reduced with daily preventive use of chlorhexidine and essential oil mouth rinses. Topical pain control for aphthous ulcers and oral mucositis can be achieved through the use of certain over-the-counter and prescription medications, which may contain benzocaine or lidocaine.
- Prescription antifungal therapy (e.g., nystatin) is indicated in xerostomic patients/clients with oral fungal infections (e.g., candidiasis).
- Denture wearing can be affected by xerostomia, and thus effective management of dry mouth is indicated.
Oral manifestations
- Xerostomia is the subjective feeling of oral dryness, which may be associated with reduced salivary flow (i.e., hyposalivation), change in saliva composition (e.g., from serous to mucous), or have no identifiable cause. Typically, a reduction in salivary flow of more than 50% is required before clinical symptoms develop.
- While dry mouth is a common problem that may be little more than a nuisance in mild, time-limited cases, it can also alter enjoyment of food and the health of teeth. This is because saliva enhances the ability to taste and swallow, in addition to helping prevent tooth decay by limiting bacterial growth and washing away food particles.
- Signs of xerostomia include the tongue blade sign (when the oral mucosa is touched with a tongue blade, the blade sticks); lipstick sign (lipstick sticks to the labial surface of the maxillary teeth); and cervical caries.
- Drug-induced xerostomia is a combination of reduced salivary flow and changes in both the nature and quality of the residual saliva. More than 500 medications cause xerostomia, making it a very common reported oral side effect, particularly amongst the elderly.3
- Older adults are at increased risk for root caries because of increased use of medications that produce xerostomia, in conjunction with increased gingival recession that exposes root surfaces.
- Xerostomia-induced dental caries are evident along the gingival margin on exposed lingual and buccal root surfaces, at and underneath crown margins, and in root furcations. Caries can lead to extensive tooth destruction and loss. Increased biofilm acidity also contributes to dentinal hypersensitivity.
- Oral infections are more frequent in xerostomic patients/clients. Fungal infections (especially oral candidiasis) may manifest as white plaques overlying reddened oral mucosa, burning mouth syndrome, angular cheilitis, and symptomatic geographic tongue.
- Because salivary mucins lubricate the oral mucous membranes, protect against ulceration and penetration of toxins, and assist with wound healing and repair, by definition these functions are compromised in patients/clients with hyposalivation.
- Aphthous ulcers are common in persons with xerostomia, given the friability of their mucous membranes.
- Other oral manifestations of hyposalivation may include dysgeusia (altered taste); halitosis (bad breath); oral dysesthesia (burning/tingling in the mouth); dysphagia (difficulty swallowing); difficulty speaking; fissured and inflamed tongue with atrophy of filiform papillae; dry, pale, or red and atrophic oral mucosa; oral mucositis; mouth soreness; dry, sore, and cracked lips and angles of the mouth; and thirst.
- Clinical findings do not always correlate with the symptoms experienced.
- Ascending/suppurative sialadenitis (infection of the major salivary glands — usually the parotid) is associated with hyposalivation, because bacteria are able to ascend the ductal system against the diminished flow of saliva.
- Depending on the underlying cause of xerostomia, specific disease- or condition-related manifestations may be found in the mouth; for example, nicotine/tar-stained teeth in the patient/client who smokes tobacco or “meth mouth” in the patient/client who smokes acidic methamphetamine.
Related signs and symptoms
- Xerostomia is very common. Prevalence is at least 20% in the general population, with increased prevalence in females (up to 30%) and the elderly (up to 50%).
- Diabetes, Parkinson’s disease, hypothyroidism, and autoimmune diseases (including Sjögren syndrome and rheumatoid arthritis) can affect the salivary glands, in addition to causing other systemic signs and symptoms. Other causes of dry mouth include certain cancer treatments4 (e.g., radiation therapy of the salivary glands) and damage to the glands’ nerve supply. Dental hygienists should be alert to xerostomia risk factors — including underlying disease conditions, medications, and therapeutic interventions — during the medical history-taking process.
- Depending on the underlying pathologic condition, extra-oral symptoms that may occur together with xerostomia include xerophthalmia (dry eyes), inability to cry, dryness of other mucosa (e.g., nasal, throat, and/or genital), and dysphonia (voice changes).
- Because salivary mucins and enzymes play a role in initiating the breakdown of food in preparation for swallowing and digestion, xerostomic patients/clients may experience gastrointestinal issues related to their inability to adequately digest food. This may lead patients/clients to make poor food choices and decrease eating due to discomfort, disinterest, or chewing difficulties; these risks are heightened in patients/clients taking medications that cause taste alteration as a side effect. Associated weight loss may alter the fit and comfort of dentures and other oral appliances. Weight loss and poor nutritional status are of particular concern in persons with serious medical conditions or undergoing cancer treatment.
References and sources of more detailed information
- Auluck A. How do I Manage a Patient with Xerostomia/Dry Mouth? J Can Dent Assoc 2016;82:g1. https://jcda.ca/g11
- Salimi F, Saavedra F, Andrews B, FitzGerald J, Winter SC. Trans-cutaneous electrical nerve stimulation to treat dry mouth (xerostomia) following radiotherapy for head and neck cancer. A systematic review. Ann Med Surg (Lond). 2021 Feb 3;63:102146. doi: 10.1016/j.amsu.2021.01.094. PMID: 33664943; PMCID: PMC7903056.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903056/ - Furness S, Worthington HV, Bryan G, Birchenough S, McMillan R. Interventions for the management of dry mouth: topical therapies. Cochrane Database Syst Rev. 2011;(12):CD008934. Published 2011 Dec 7. doi:10.1002/14651858.CD008934.pub2
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008934.pub2/full - Ontario Dental Hygienists’ Association
https://odha.on.ca/wp-content/uploads/2016/08/ODHA-Facts-Dry-Mouth.VFS18-copyright.pdf - Dental Hygiene Canada / Canadian Dental Hygienists Association
https://www.dentalhygienecanada.ca/DHCanada/Seniors/Denture_and_Mouth_Care/DHCanada/Seniors/Dry_Mouth.aspx - National Institute of Dental and Craniofacial Research, National Institutes of Health
https://www.nidcr.nih.gov/health-info/dry-mouth - American Dental Association
https://www.ada.org/en/member-center/oral-health-topics/xerostomia - Mayo Clinic
http://www.mayoclinic.com/health/dry-mouth/HA00034 - The University of Chicago Medicine
https://www.uchicagomedicine.org/cancer/types-treatments/prostate-cancer/treatment/lutetium-177-psma-therapy-for-prostate-cancer - Dimensions in Dental Hygiene
https://dimensionsofdentalhygiene.com/article/effective-approaches-addressing-xerostomia/
https://dimensionsofdentalhygiene.com/article/xerostomia-diagnosis-and-management/ - Today’s RDH
https://www.todaysrdh.com/understanding-and-managing-xerostomia/ - RDH Magazine
https://www.rdhmag.com/patient-care/article/14304535/strategies-for-managing-xerostomia
https://www.rdhmag.com/patient-care/xerostomia/article/14302288/defeating-dry-mouth-what-to-know-and-how-to-help-your-patients - Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020.
- Little JW, Miller CS, and Rhodus NL. Little and Falace’s Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.
- Ibsen OAC and Peters SM. Oral Pathology For The Dental Hygienist (8th edition). St. Louis: Elsevier; 2023.
- Regezi JA, Sciubba JJ, and Jordan RCK. Oral Pathology: Clinical Pathologic Correlations (7th edition). St. Louis: Elsevier; 2017.
FOOTNOTES
1 Immunotherapy is biological therapy that treats disease by activating or suppressing the immune system. It is increasingly being used to treat cancer.
2 For example, transcutaneous nerve stimulation (TENS) can be used to improve saliva flow in patients/clients who have undergone radiation therapy for head and neck cancer.
3 For example, prescribed medications for hypertension (especially diuretics), depression, anxiety, and overactive bladder often cause dry mouth. Inhalers for asthma or chronic obstructive pulmonary disease (COPD) can cause dry mouth without decreasing salivary flow. Commonly implicated over-the-counter medications include antihistamines and decongestants.
4 Lutetium-177 is an evolving radiation treatment for advanced, metastatic prostate cancer. Lutetium-177 is a beta particle emitter (administered by intravenous infusion) that targets prostate specific membrane antigen (PSMA), which is expressed by prostate cancer cells. However, PSMA is also expressed by cells of the salivary glands, and thus xerostomia is a side effect of lutetium therapy. While access to lutetium-177 is currently limited in Ontario, it is available in other provinces, the USA, and other countries.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.