Clinical examination
It is important to examine the mouth and oral mucosae when a patient experiences dry mouth, and a pen torch to give adequate illumination is essential. The condition of lips, gums and teeth should be assessed and the amount of saliva noted.

In advanced xerostomia, an erythematous, pebbled, cobblestoned, or fissured tongue and atrophy of the filiform papillae can be seen. The surfaces may be erythematous and appear parched.22 It is important to examine under the tongue, so pathology in this area is not missed.

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Patients should be asked to remove any dentures, so that all surfaces can be observed. Palpating a dry oral mucosa may result in the examiner’s fingers adhering to mucosal surfaces. Check for coexisting pathology, such as oral thrush.

The observation of patients while they are eating, especially when they are attempting to eat dry foods, such as biscuits or bread, can reveal a prolonged and laboured chewing time. Other features, such as halitosis, cracked lips and fissures, may be present in these patients. If the patient is on oxygen therapy, check to see if it is humidified.

Therapy and symptomatic treatment
All strategies should first aim to address reversible causes of xerostomia. The patient’s medications should be studied to consider whether any can be stopped or reduced. Alternatives may have fewer antimuscarinic properties. Any underlying infections, such as candidiasis, should be treated with antifungal tablets, suspensions (such as nystatin) or gels (miconazole).

Patients who are mouth-breathing should be tried on a short-term course of topical nasal decongestants. Dry mouth may be due to overwhelming anxiety, so this possible cause also needs to be addressed.

Practical options for symptomatic treatment can provide relief. Sipping water throughout the day may be sufficient for some patients. Holding ice chips in the mouth to provide some moisture can also alleviate symptoms. Other measures include sucking on pineapple slices, frequent sips of cold orange squash or semi-frozen fruit juice, or the use of sugar-free chewing gum. Patients may find using olive oil useful and some dry mouth products containing olive oil have been shown to be beneficial.23

Saliva substitutes have been developed for patients with xerostomia. There are a variety of formulations, including rinses, aerosols, chewing gums and dentifrices, and these may also have a role in promoting salivary gland secretions.24 It may help patients to use these formulations before meals.

Dentate patients should use fluoride-containing saliva substitutes and maintain scrupulous oral hygiene. Gels might be more useful overnight, because they take longer to disperse. Acupuncture has been shown to have some benefits in patients with xerostomia.25 Some things are best avoided. Lemon juice quickly depletes salivary glands of saliva, and commercial mouth rinses containing alcohol may lead to desiccation of the oral mucosa. Saliva substitutes may contain animal mucin, usually porcine, and some patients may not wish to use them.

Systemic treatment with pilocarpine is sometimes used following radiotherapy and in Sjogren’s syndrome. This is a parasympathomimetic drug that can increase salivary gland secretion. However, there are a number of side-effects.26 It can cause cardiac arrhythmias and should be avoided in patients with significant cardiac conditions; it is contraindicated in uncontrolled asthma and narrow-angle glaucoma.

Dr Mark Taubert is a specialist registrar in palliative medicine at the University Hospital of Wales. Competing interests: None declared 

1. Ghezzi EM, Lange LA, Ship JA. Determination of variation of stimulated salivary flow rates. J Dent Res 2000;79:1874-8.
2. Sreebny LM, Valdini A. Xerostomia: a neglected symptom. Arch Intern Med 1987;147:1333-7.
3. Gerdin EW, Einarson S, Jonsson M et al. Impact of dry mouth conditions on oral health-related quality of life in older people. Gerodontology 2005;22:219-26.
4. Cassolato SF, Turnbull RS. Xerostomia: clinical aspects and treatment. Gerodontology 2003;20:64-77.
5. Samaranayake LP. Host factors and oral candidosis. In: Samaranayake LP, MacFarlane TW (editors). Oral candidosis. Wright, London, 1990.
6. International Dental Federation. Working Group 10 of the Commission on Oral Health, Research and Epidemiology (CORE). Saliva: its role in health and disease. Int Dent J 1992;42:287-304.
7. Provenza DV. Oral Histology. Lippincott, Philadelphia, 1964.
8. Cooper JS, Fu K, Marks J et al. Late effects of radiation in the head and neck region. Int J Radiat Oncol Biol Phys 1995;31:1141-64.
9. Daniels TE, Wu AJ. Xerostomia – clinical evaluation and treatment in general practice. J Can Dent Assoc 2000;28:933-41.
10. Carranza FA, Newman MG, Takei TT. Carranza’s Clinical Periodontology. WB Saunders Company, Philadelphia, 2002.
11. Wu AJ, Ship JA. A characterization of major salivary gland flow rates in the presence of medications and systemic diseases. Oral Surg Oral Med Oral Pathol 1993;76:301-6.
12. Addington-Hall J, McCarthy M. Dying from cancer: results of a national population-based investigation. Palliat Med 1995;9:295-305.
13. Wynn RL, Meiller TF. Artificial saliva products and drugs to treat xerostomia. Gen Dent 2000;48:630-6.
14. Hip JA, Pillemer SR, Baum BJ. Xerostomia and the geriatric patient. J Am Geriatr Soc 2003;50:535-43.
15. Moore PA, Guggenheimer J, Etzel KR et al. Type 1 diabetes mellitus, xerostomia, and salivary flow rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:281-91.
16. Sreebny LM, Yu A, Green A et al. Xerostomia in diabetes mellitus. Diabetes Care 1992;15:900-4.
17. Tenovuo JO. Human Saliva: Clinical Chemistry and Microbiology Volume 1. CRC Press Inc, Florida, 1989.
18. Russell S, Reisine S. Investigation of xerostomia in patients with rheumatoid arthritis. J Am Dent Assoc 1998;129:733-9.
19. Al-Hashimi I. The management of Sjogren’s syndrome in dental practice. J Am Dent Assoc 2001;132:1409-17.
20. Greenspan B. Xerostomia: diagnosis and management. Oncology 1996;10:7-11.
21. Nagler R, Marmary Y, Krausz Y et al. Major salivary gland dysfunction in human acute and chronic graft-versus-host disease (GVHD). Bone Marrow Transplant 1996;17:219-24.
22. Guggenheimer J, Moore PA. Xerostomia: etiology, recognition and treatment. J Am Dent Assoc 2003;134:61-9.
23. Ship JA, McCutcheon JA, Spivakovsky S et al. Safety and effectiveness of topical dry mouth products containing olive oil, betaine, and xylitol in reducing xerostomia for polypharmacy-induced dry mouth. J Oral Rehabil 2007;34:724-32.
24. Rhodus NL, Bereuter J. Clinical evaluation of a commercially available oral moisturizer in relieving signs and symptoms of xerostomia in postirradiation head and neck cancer patients and patients with Sjogren’s syndrome. J Otolaryngol 2000;29:28-34.
25. Rydholm M, Strang P. Acupuncture for patients in hospital- based home care suffering from xerostomia. J Palliat Care 1999;15:20-3.
26. Johnson JT, Ferretti GA, Nethery WJ et al. Oral pilocarpine for post-irradiation xerostomia in patients with head and neck cancer. N Engl J Med 1993;329:390-5.

Originally published in the March 2009 edition of MIMS Oncology & Palliative Care.