2. www.webmd.com/oral-health/guide/dental-health-dry-mouth – Biotene AD

3. www.ada.org/3014.aspx – links to http://www.sjogrens.org/

4. www.cancer.net/patient/All+About+Cancer/Treating
+Cancer/Managing+Side+Effects/Dry+Mouth+or+Xerostomia

5. www.causeofdrymouth.com/

6. www.nlm.nih.gov/medlineplus/ency/patientinstructions/000032.htm

7. www.healthline.com/galecontent/dry-mouth (treatments)

8. www.livestrong.com/article/75931-thirst-dry-mouth-night/

9. www.agd.org/public/OralHealth/drymouth/

10. www.nidcr.nih.gov/oralhealth/topics/drymouth/

The three major salivary glands, which are located near the jawline, are the parotid, the submandibular, and the sublingual. The bulk of an average person’s saliva is produced by the parotid and the submandibular; the sublingual only produces about 5%. Hundreds of smaller glands, known as the minor salivary glands, are also present throughout the mouth and throat to support the function of the major glands.

Salivary blockages

Salivary duct blockages are caused by cysts, salivary stones, or infections. Cysts may result from prior trauma to the glands, usually related to injury, radiation therapy, or surgery. Salivary stones can arise with a condition known as sialolithiasis. The stones, which are formed from calcium, can lodge in the ducts and inhibit the passage of fluids (Cedars-Sinai, n.d.). Infections cause inflammation, which in turn can close off some salivary ducts.

Parotitis and sialadenitis are two terms for salivary gland infections. Parotitis implies a bacterial or viral infection of the parotid gland, while sialadenitis is a bacterial infection. Viral salivary gland infections have been associated with mumps and HIV/AIDS. According to Cedars Sinai, “Coxsackie viruses, echovirus and cytomegalovirus” can also attack the salivary glands and cause inflammation (n.d.). Bacterial infections result from improper oral hygiene or from the presence of salivary duct stones. Individuals who already have low saliva flow are also more susceptible to bacterial sialadenitis.

Infection is usually accompanied by fever, mouth pain, and facial swelling. Viral infections are not treatable, and so they must run their course. Bacterial infections are addressed with antibiotics. If swelling is present, surgical drainage of the gland may be required.

Salivary gland tumors

Tumors of the salivary glands are usually benign, although patients with exposure to radiation may be at risk for cancerous salivary tumors. Tumors usually present themselves visually, as a large mass on a cheek, in the mouth, or on the tongue. As the mass gets larger in size, the patient will exercise increasing pain from the tumor.  

More than three-quarters of all benign salivary tumors are what’s called pleomorphic adenomas, which typically appear in the parotid gland. This is a slow-growing tumor that can become very large over time if left untreated. Another common tumor affecting the salivary glands is Warthin’s tumor, which also tends to appear in the parotid gland. Warthin’s tumor has been associated with smoking and aging.

Salivary gland tumors are usually removed surgically.

Dry mouth symptoms resulting from these conditions may be managed with prescription and/or over-the-counter remedies, until the underlying condition has been resolved. If the salivary glands have been damaged, the patient may continue to suffer from dry mouth long after the underlying cause has been treated.

Decreased salivary flow is the most logical reason why someone would experience dry mouth. However, studies indicate that not all patients complaining of dry mouth have decreased salivary flow. Therefore, physicians generally diagnose dry mouth with a series of subjective questions. This is a primary reason why there isn’t more hard data on the condition of dry mouth; it is problematic to quantify, compare, and analyze sets of patient responses to subjective questions.

Questions used by doctors to diagnose dry mouth vary widely. Mahvash Navazesh, D.M.D. (2003), advises these queries, to determine if further clinical tests are necessary:

• “Does the amount of saliva in your mouth seem to be too little, too much or you do not notice it?
• Do you have any difficulties swallowing?
• Does your mouth feel dry when eating a meal?
• Do you sip liquids to aid in swallowing dry food?” (para. 2)

Clinical studies have confirmed the presence of dry mouth with more direct questions, such as:

Table source: Sreebney and Vissink (2010)

From the patient’s perspective

If your mouth is uncomfortably dry, occasionally or frequently, you probably don’t need any further evidence to confirm what you feel. You can assess the severity of your symptom set, however, by asking these questions:

• Are your lips dry?
• Is your tongue rough and dry?
• Do you have trouble chewing and swallowing?
• Has your sense of taste changed?
• Is your throat dry and/or burning?

Once you run through these self-checks, you are apt to be focused on finding a solution. A consultation with your doctor is the appropriate first step. Your doctor may start by reviewing the medications you take. Depending on other symptoms you have, your doctor may also test you for certain disorders. Be prepared, however, to learn that there is no clear explanation for your dry mouth symptoms.

In that case, your doctor may offer you some coping strategies. Many of these are common sense for good health: stay hydrated, avoid smoking, limit alcoholic and caffeinated beverages, and eat a well-balance diet. Sugar-free gum and a good, moisturizing mouth rinse may alleviate dry mouth discomfort as well.

References

Navazesh, M. (2003) How can oral health care providers determine if patients have dry mouth? J Am Den Assoc, 134(5), 613-618. Retrieved from http://jada.ada.org/cgi/content/full/134/5/613

Sreebny, L.M. & Vissink, A. (2010). Dry mouth. The malevolent symptom: A clinical guide. Ames, Iowa: Wiley-Blackwell.

Hyposalivation: often, but not always present

Many laymen use the terms “dry mouth,” “xerostomia,” and “hyposalivation” interchangeably. Xerostomia is the medical term for dry mouth, and so these two terms can be accurately used as synonyms. Both refer to the subjective feeling of dryness in the oral cavity.

Hyposalivation is a different, but related condition. The word means inadequate flow of the saliva fluid. This is a less subjective, more quantifiable condition that is often assumed to be the cause of dry mouth. But, not all patients who report dry mouth symptoms actually have insufficient salivary flow. When hyposalivation and dry mouth appear together, the patient will typically experience a more severe symptom set, as described below.

Oral symptoms

The impact on oral health from dry mouth and hyposalivation has been widely documented. Saliva is a powerfully protective fluid that wards off tooth decay and infections. Patients who do not produce enough saliva are at increased risk of dental carries, accumulation of plaque, mouth sores, and mouth infections.

Further, patients may experience a burning or sore feeling in the mouth and tongue, along with changes in taste perception. The individual may become generally less sensitive to taste, and salty and acidic foods may begin to irritate the mouth. A decline in sensitivity to smell can also occur. When the individual does not have enough saliva to moisten food thoroughly, chewing will become more difficult and less enjoyable. Speech can even be impacted, because the tongue feels dry and sticky.

If the hyposalivation is related to an infection, blockage, or tumor in the salivary glands, then external swelling may also be present. The major salivary glands are located along the jawline. The parotid gland is closest to the ear, the submandibular gland is midway to the chin, and the sublingual gland is closest to the chin. These major glands are supported by many smaller glands located throughout the mouth and throat. 

Dryness of eyes, nose, and throat

Dryness of the eyes, nose, and throat may also appear with dry mouth. Nasal dryness often manifests as recurrent nose bleeds, while dry eyes burn or feel gritty. Contact lenses become uncomfortable, vision may blur, and eyes may quickly tire from reading. A dry throat will feel hoarse and scratchy.

Dry eyes and dry mouth together could indicate Sjorgren’s Syndrome, an autoimmune disorder than can affect various organs within the body.

Fatigue and anxiety

For many reasons, dry mouth can be associated with fatigue and anxiety. These symptoms could be related to an underlying condition that is causing the dry mouth (such as Sjorgren’s Syndrome). Or, they could be caused by the ways in which dry mouth affects one’s quality of life. A decline in the ability to chew, taste, smell, and see takes away many sources of personal entertainment and enjoyment. Patients also complain of sleeping problems. The chronically dry mouth repeatedly awakens the patient at night, leading to fatigue and other health problems associated with insufficient sleep.

The dryness usually results from open-mouth sleeping, which is common among individuals suffering from obstructive sleep apnea or OSA. The breathing pauses that characterize OSA result from relaxation of the muscles that keep the airway open; it is possible that a similar relaxation of the facial muscles may cause the individual’s mouth to open as she sleeps. Or, the open-mouth sleeping could be just habitual.

Other signs of OSA include snoring, frequent waking at night, and decreased ability to concentrate—a by-product of fatigue. Individuals experiencing these symptoms should talk to their physician. A true diagnosis of sleep apnea does require participation in a sleep test.

Sleep apnea leads to lower levels of blood oxygen, which wakes the afflicted individual and robs her of restorative sleep. In some cases, the condition is serious enough to require surgery to increase the posterior airway space.

CPAP-induced dry mouth

Surgery, however, is not the first choice of treatment. The safer and more common course of action is CPAP therapy. A CPAP is a ventilation device that uses forced air pressure to keep the individual’s airway open at night. The air pressure is delivered through a full-face mask, nasal mask, or nasal pillows. Dry mouth is a routine side effect of CPAP usage, particularly among inexperienced CPAP users. The symptoms can be uncomfortable enough to cause some patients to discontinue therapy.

For those using nasal masks or nasal pillows, dry mouth can be a sign of open-mouth sleeping. This should be addressed immediately, because an open mouth limits the effectiveness of the CPAP. If air is leaking out the mouth, the device cannot effectively hold the airway open. Strategies to address open-mouth sleeping include using a flexible chin strap that gently holds the mouth shut, or switching to a full-face mask. The full-face mask covers both mouth and nose.

Individuals already using a full-face mask may suffer from dry mouth due to the pressurized air flow. In this case, the first remedy is to try using a heated humidifier that attaches to the CPAP.  These patients should also check the fitting of the mask and quality of the mask’s seal. Other strategies include:

• Keeping a glass of water nearby to quench thirst during waking episodes
• Using a saline nasal spray before bedtime
• Using of an over-the-counter, dry mouth remedy such as Orazyme
• Sleeping on one’s side, rather than on one’s back

Many CPAP users have reported an improvement in dry mouth symptoms over time and through continued use of the ventilator.

The following are brief overviews of five disorders associated with dry mouth.

Sjögren’s Syndrome

Sjögren’s Syndrome is an autoimmune disorder that causes inflammation of exocrine glands, which produce proteins and/or mucus within the body. The salivary and other glands, under attack by white blood cells, limit their production—causing dry eyes and dry mouth as the most obvious symptoms.

The disorder can occur in the body by itself or in conjunction with another autoimmune disease, such as rheumatoid arthritis. Sjögren’s is far more common in women than in men, and tends to appear at middle age. According to Sjögren’s Syndrome Foundation,¹ up to 4 million Americans live with Sjögren’s.

Diabetes

Poorly controlled diabetes can cause damage to the salivary glands, which results in decreased saliva production. Even well controlled diabetics, however, are at risk of dry mouth—often resulting from medications. Hundreds of drugs in several classes are thought to have dry mouth as a side effect. These drug classes include those used to treat blood pressure, anxiety, inflammation, and allergies, all symptoms that can plague a diabetic. Diabetics who smoke or do not stay properly hydrated are even more likely to experience chronic dry mouth.

Sarcoidosis

Sarcoidosis is a disease that causes inflammation. This inflammation can occur throughout the body, but tends to begin in the lungs or lymph nodes. The salivary glands can become inflamed as well, and this would cause a decrease in saliva and the associated dry mouth discomfort.

Not enough is known about the causes of sarcoidosis. Experts do believe that it afflicts black individuals in the U.S. more than white individuals. But women and men are equally targeted. Up until the mid-20^th century, sarcoidosis was believed to be relatively uncommon in the U.S., but it has long been a recognized disease in Scandinavian countries. Sarcoidosis tends to appear between the ages of 20 and 40.  

Amyloidosis

The term amyloidosis refers to a group of diseases that involves the build-up of proteins in the body. This build-up causes organs, such as the heart, lungs, kidney, or spleen, to malfunction. When an individual with amyloidosis has dry mouth (along with other symptoms like dry eyes, blurred vision, intolerance to heat, and gastrointestinal problems), this possibly indicates a broader failure of the autonomic nervous system.

Amyloidosis occurs most often in individuals older than 40, and its exact cause is unknown. According to the Milton S. Hershey Medical Center College of Medicine, eight in every 1 million people is afflicted with the disease.²

HIV/AIDS

Dry mouth in itself is not a sign of HIV or AIDS, although dry mouth is often associated with these diseases. As with Sjögren’s Syndrome, HIV infection can cause damage to the salivary glands, which creates an imbalance in salivary production. Dry mouth can also be caused by the medications used to treat HIV/AIDS and related complications, or by the anxiety of living with one of these conditions.

1 http://www.sjogrens.org/home/about-sjogrens-syndrome

2 http://www.hmc.psu.edu/healthinfo/a/amyloidosis.htm

The complex functions of saliva are generally taken for granted, until you personally experience a decrease in salivary production. Such a decrease leads to a variety of unpleasant conditions, including dry mouth, swallowing problems, tooth decay, and mouth infections. Based on these conditions alone, one could guess that saliva works to keep the mouth moist, prepare food for swallowing, and protect the teeth and mouth from dangerous bacteria. And, not surprisingly, this guess would be pretty close to accurate, as these are the primary functions of the saliva fluid. 

Maintaining mouth moisture

Mouth moisture is important for comfort purposes, but it also plays a key role in oral hygiene. Saliva’s continued presence in the mouth has a cleansing function—it washes away food particles, debris, and bacteria that cause tooth decay and bad breath. When salivary production is limited, this washing process is less effective.

Preparing food for tasting and swallowing 

Saliva makes food easier to swallow and tastier too. When saliva combines with bits of chewed food, it creates a moistened ball—called a bolus—that can move down the esophagus without tearing or scratching tissue on the way. Saliva also lines the esophagus as an additional layer of protection against chewed food. 

The role saliva plays in tasting is relatively well documented. Saliva prepares food for tasting and stimulates the taste buds. Taste buds are less sensitive with dry foods, and so saliva’s moistening properties allow taste receptors to do their best work, so to speak. The fluid also helps transport the chewed food to the tongue, where the flavors can be recognized and enjoyed.

Taste is both a pleasurable and necessary part of eating. Once the tongue recognizes the flavors of the food, it signals the brain to begin producing the appropriate digestive fluids.

Protection of mouth and teeth

Saliva is also responsible for a host of protective actions, including:

• Maintenance of pH balance and neutralization of acids. The consumption of sugary foods, for example, can prompt changes in plaque pH and production of acids that erode tooth enamel and eventually result in tooth decay.
• Killing harmful bacteria. Saliva is loaded with antimicrobial components to protect your mouth (and your body) from harmful micro-organisms. These helpful components include antiviral, antifungal, and antibacterial proteins. Some harmful species can be destroyed by saliva, while others are merely contained to prevent overgrowth.
• Coating teeth. Saliva contains proteins that coat teeth and protect their surfaces from acid erosion. 
• Promoting remineralization and limiting demineralization of teeth. The mucins in saliva coat the teeth to defend against calcium loss. When calcium loss does occur, the calcium within saliva promotes remineralization.

Saliva does far more than help you chew, taste, and digest your food. Indeed, it is a superhero defense against numerous tooth and mouth problems. If you are experiencing a decrease in saliva production, don’t discount your symptoms. Talk to your physician right away. 

Sreebny, L.M. & Vissink, A. (2010). Dry mouth. The malevolent symptom: A clinical guide. Ames, Iowa: Wiley-Blackwell.

The following are some of the drug classes typically associated with dry mouth symptoms.

• Appetite suppressants, including phentermine, phendimetrazine, benzphetamine, sibutramine, and diethylpropion. Brand names associated with these drugs include Anorex SR, Adipost, Didrex, and Zantryl.
• Antacids and ulcer treatments, including Prilosec (omeprazole), Prevacid (lansoprazole), and Protonix (pantoprazole). 
  
• Anxiety treatments, such as lorazepam, diazepam, and alprazolam, also known as Ativan, Valium, and Xanax, respectively.
• Antispasmodics and anticholinergics, which are commonly used to treat irritable bowel syndrome, cramping, and other intestinal disorders. Medications in this class include Anaspaz (hyoscyamine), Bentyl (dicyclomine), and Donnatal (hyoscyamine with atropine, phenobarbital, scopolamine). The motion sickness medication Transderm-Scop (scopolamine) is also in this group.
  
• Anticonvulsants, for the treatment of epilepsy as well as bipolar disorder. Neurontin (gabapentin) and Tegretol (carbamazepine) are both anticonvulsants.
• Antidepressants, such as Celexa, Paxil, Prozac, Wellbutrin, and Zoloft. The molecule names for these brands are citalopram, paroxetine, fluoxetine, bupropion, and sertraline, respectively.
• Antihistamines, both prescription and over-the-counter formulations. Medications in this group include Actifed (triprolidine with pseudoephedrine), Benadryl (diphenhydramine), Chlor-Trimeton (chlorpheniramine), Claritin (loratadine), Vistaril (hydroxyzine), and Zyrtec (cetirizine).
• Blood pressure medications. Many antihypertensives are associated with dry mouth, including Accupril, Flomax, and Norvasc—or quinapril, tamsulosin, and amlodipine, respectively.
• Bronchodilators, for the treatment of asthma and chronic obstructive pulmonary disease. Medications in this category include Alupent (metaproterenol), Combivent (ipratropium/albuterol), Spiriva (tiotropium), and Ventolin (albuterol).
• Diarrhea treatments, including Imodium AD (loperamide) and Lomotil (diphenoxylate with atropine).
• Diuretics, such as Diurese (trichlormethiazide), Lasix (furosemide), and Zaroxolyn (metolazone).
• Over-the-counter pain relievers. Motrin (ibuprofen) and Naprosyn (naproxen) have both been known to induce dry mouth.
• Parkinson’s treatments, such as biperiden, pergolide, amantadine, and ropinirole. The brand names associated with these medications are Akineton, Permax, Symmetrel, and Requip.

Note that this is not an exhaustive list. If you begin to experience dry mouth conditions and you believe your medication is the cause, speak to your doctor directly about the problem. Do not make any changes to your medication routine without your doctor’s permission—no matter how aggravating your dry mouth condition may be. There are coping strategies and over-the-counter products that can help alleviate your dry mouth symptoms.

Chronic versus temporary dry mouth  

Xerostomia is the medical term for dry mouth. The condition is also referred to as hyposalivation. Both xerostomia and hyposalivation imply a prolonged form of dry mouth, rather than temporary or occasional mouth dryness. Besides the frequency of symptoms, a main differentiator between occasional and chronic dry mouth may be the underlying cause.

Several factors may induce occasional mouth dryness, including:

• Stress or anxiety
• Short-term illness and fevers
• Dehydration
• Smoking
• Open-mouth breathing

 More severe, chronic dry mouth conditions often result from:

• Medication, both prescription and over-the-counter
• Disease or infection
• Use of illicit drugs

These lists are not complete, however. You may indeed suffer from short-term or chronic dry mouth in the absence of the above factors.

Who has dry mouth

Sreebney and Vissink (2010) estimate that 20 percent of adults suffer from dry mouth. That equates to 44 million people in the U.S.

Experts believe dry mouth is more common in women than in men, particularly in post-menopausal women. Further, elderly individuals complain more regularly of dry mouth than their young and middle-aged counterparts. The link between age and dry mouth is likely related to the increasing number of drugs people ingest as they age (Sreebney & Vissink, 2010). It could also be that saliva production declines with age.

Long-term consequences

While dry mouth may begin as just an annoyance, it should not go untreated—particularly if it begins to happen more and more often. Over time, dry mouth can contribute to a wide variety of oral problems, including tooth decay, gum disease, and mouth infections. Other conditions associated with dry mouth include bad breath, irritated tongue, and mouth sores. The most serious consequences include loss of taste and tooth loss.

Over-the-counter remedies

You can use an over-the-counter remedy to alleviate both temporary and chronic dry mouth. As a first step, however, try to identify the cause. Speak with your doctor about your symptoms and brainstorm potential factors. Are you taking a new medication? Has another disease or illness flared up to cause the dry mouth? Are you dehydrated?

While identifying and eliminating the cause is the most permanent remedy, it’s not always possible to do. It is problematic, for example, when a necessary medication, such as a bronchodilator for asthma, is causing the mouth dryness. In these situations, you can address your dry mouth symptoms by:

• Drinking plenty of water to stay hydrated
• Brushing and flossing teeth, and visiting a dentist regularly to maintain tooth health
• Using an over-the-counter rinse like Orazyme to relieve dryness
• Keeping sugar-free gum handy to chew when you cannot rinse
• Avoiding dusty or windy environments that could irritate your nasal passages
• Using lip balm to keep lips moist

Your doctor may have additional suggestions to address your specific health situation.