By David F. Murchison, DDS, MMS, Clinical Professor, Department of Biological Sciences;Clinical Professor, The University of Texas at Dallas;Texas A & M University Baylor College of Dentistry
Dry mouth is caused by a reduced or absent flow of saliva. This condition can cause discomfort, interfere with speech and swallowing, make wearing dentures difficult, cause bad breath (halitosis), and worsen oral hygiene by causing a decrease in the acidity of the mouth and an increase in bacterial growth. Longstanding dry mouth can result in severe tooth decay and candidiasis of the mouth. Dry mouth is a common complaint among older people.
Dry mouth occurs when the salivary glands (glands in the mouth that produce saliva) malfunction and thus decrease saliva production. There are many causes (see Table: Some Causes of Dry Mouth).
The most common causes of dry mouth are
- Radiation to the head and neck (for cancer treatment)
Drugs are the most common cause overall. About 400 prescription drugs and many nonprescription (over-the-counter) drugs cause a decrease in saliva production. The most common classes of drugs include the following:
- Drugs that have anticholinergic effects (drugs that block acetylcholine)
- Antiparkinsonian drugs (drugs used to treat Parkinson disease)
- Cancer chemotherapy drugs
Many commonly used drugs have anticholinergic effects (see Anticholinergic: What Does It Mean?). Dry mouth is only one among many anticholinergic side effects.
Chemotherapy drugs cause severe dryness and mouth sores (stomatitis) while they are being taken. These problems usually end after the drugs are stopped.
Other common drugs that cause dry mouth include certain antihypertensives (drugs used to lower high blood pressure), anxiolytics (drugs used to treat anxiety disorders), and antidepressants (drugs used to treat depression).
Illegal methamphetamine use has resulted in a disorder called meth mouth, which is severe tooth decay caused by methamphetamine-induced dry mouth. The damage is worsened by the tooth grinding and clenching caused by the drug and by the heat of the inhaled vapor. This combination causes very rapid destruction of teeth and a lifetime of dental problems for younger people.
Tobacco use usually causes a decrease of saliva.
Radiation therapy for head and neck cancer can severely damage the salivary glands, often causing permanent dryness. Even low doses of radiation can cause temporary drying.
Less common causes of dry mouth include bodywide (systemic) disorders. Dry mouth is very common among people with the rare disorder Sjögren syndrome. Some people with diabetes or HIV infection have problems with dry mouth.
Not all people with a dry mouth need to be immediately evaluated by a doctor. The following information can help people decide whether a doctor’s evaluation is needed and help them know what to expect during the evaluation.
In people with dry mouth, certain symptoms and characteristics are cause for concern. They include
- Extensive tooth decay
- Dry eyes, dry skin, rash, or joint pain
- Risk factors for HIV infection
When to see a doctor
People who have warning signs should see a doctor right away. People with extensive tooth decay should have a dental examination. People with a dry mouth but no warning signs and who otherwise feel well may see their doctor within a week or so.
What the doctor does
Doctors first ask questions about the person’s symptoms and medical history. Symptoms of dry or irritated eyes, dry skin, rash, and/or joint pain raise the possibility of Sjögren syndrome. Doctors also ask about a history of past or current radiation treatment, head and neck trauma, and a diagnosis of or risk factors for HIV infection. Doctors need to know all the drugs a person is taking to find out whether any are causing the dry mouth.
Doctors then do a physical examination. The physical examination is focused on the mouth, to see the degree of dryness. If the degree of dryness is unclear, doctors can hold a tongue depressor against the inside of the cheek for 10 seconds. If the tongue depressor falls off immediately when released, the flow of saliva is considered normal. If there is difficulty removing the tongue depressor, the flow of saliva is not normal. In women, the lipstick sign, where lipstick sticks to the front teeth, may be a useful indicator of dry mouth. Doctors also examine the mouth for the presence of any sores caused by the fungus Candida albicans and check the condition of the teeth (for instance, whether there are any cavities). Unexpectedly severe tooth discoloration and decay may be a sign of illicit drug use, particularly methamphetamines.
What doctors find during the history and physical examination often suggests a cause of the dry mouth (see Table: Some Causes of Dry Mouth) and the tests that may need to be done. If the dry mouth began shortly after a new drug was started, doctors often try stopping the drug to see whether symptoms go away.
Some Causes of Dry Mouth
|Drugs with anticholinergic effects||Antidepressants
Meperidine, methadone, and other opioids
|―||Breathing through the mouth too much
Head and neck trauma (causing nerve injury)
Radiation therapy to the head and neck area
Sometimes, doctors test how well the salivary glands are functioning by measuring the flow of saliva (sialometry). People chew paraffin or apply citric acid to the tongue to stimulate the flow of saliva, and then doctors collect the saliva. Measuring the flow of saliva can help doctors determine whether the dry mouth is getting better or worse.
If doctors are unable to determine the cause of dry mouth, people should usually undergo a biopsy (removal of a sample of tissue for examination under a microscope) of a minor salivary gland on the lower lip to detect Sjögren syndrome, sarcoidosis, amyloidosis, tuberculosis, or cancer. They may also consider HIV testing.
- Treatment of the cause, including stopping causative drugs when possible
- Sometimes drugs to increase saliva production
- Saliva substitutes
- Regular oral hygiene and dental care
When possible, the cause of dry mouth is treated. For people with drug-related dry mouth whose current drug cannot be stopped or changed to another drug, drugs should be taken in the morning rather than at night, because nighttime dry mouth is more likely to cause cavities. For all drugs, easy-to-take formulations, such as liquids, should be considered. Drugs that need to be placed under the tongue should be avoided. People should drink water before swallowing capsules and tablets or before placing nitroglycerin under the tongue. People also should avoid decongestants and antihistamines.
Treatment that helps control the symptoms of dry mouth consists of measures that
- Increase existing saliva
- Replace saliva with other liquid
- Control cavities
Drugs that increase saliva production include cevimeline and pilocarpine. The main side effect of cevimeline is nausea. The main side effects of pilocarpine include sweating, flushing, and excreting large volumes of diluted urine (polyuria).
Sipping sugarless fluids frequently and chewing gum that contains xylitol helps stimulate saliva flow. Using an over-the-counter saliva substitute containing carboxymethylcellulose, hydroxyethylcellulose, or glycerin may also help.
Petroleum jelly can be applied to the lips and under dentures to relieve drying, cracking, soreness, and trauma of the lining of the mouth. A cold-air humidifier may aid mouth breathers, who typically have their worst symptoms at night.
Meticulous oral hygiene is essential. People should brush and floss regularly (including just before bedtime) and use fluoride rinses or gels daily. Newer toothpastes with added calcium and phosphates also may help prevent cavities. People should see their dentist more often for preventive dental care and plaque removal. The most effective way to prevent cavities is to use custom-fitted mouth guards for at-home fluoride application. In addition, a dentist can apply a sodium fluoride varnish 2 to 4 times per year.
People should avoid sugary or acidic foods and beverages and any irritating foods that are dry, spicy, or excessively hot or cold. People should especially avoid sugar near bedtime.
Essentials for Older People
Dry mouth is more common among older people, but this is probably due to the many drugs typically used by older people rather than aging itself.