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Therapeutics and Clinical Risk Management 2015:11 45–51
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REVIEW
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/TCRM.S76282
Diagnosis and management of xerostomia and
hyposalivation
Alessandro Villa1,2
Christopher L Connell3
Silvio Abati4
1Division of Oral Medicine and
Den tis try, B righam and Wom en’s
Hospital, Boston, MA, USA;
2Department of Oral Medicine,
Infection and Immunity, Harvard
School of Dental Medicine, Boston,
MA, USA; 3Department of General
Dentistry, Boston University Henry M
Goldman School of Dental Medicine,
Boston, MA, USA; 4Dental Clinic,
Department of Health Sciences,
University of Milan, Milano, Italy
Abstract: Xerostomia, the subjective complaint of dry mouth, and hyposalivation remain a
significant burden for many individuals. Diagnosis of xerostomia and salivary gland hypofunc-
tion is dependent upon a careful and detailed history and thorough oral examination. There exist
many options for treatment and symptom management: salivary stimulants, topical agents,
saliva substitutes, and systemic sialogogues. The aim of this review is to investigate the current
state of knowledge on management and treatment of patients affected by xerostomia and/or
hyposalivation.
Keyword: saliva stimulation, dry mouth, saliva substitutes, sialogogues
Introduction
Xerostomia is defined as the subjective complaint of dry mouth.1 Interestingly,
patients complaining of xerostomia frequently do not show any objective sign of
hyposalivation and their symptoms may be secondary to qualitative and/or quantita-
tive changes in the composition of saliva.2,3 The normal stimulated salivary flow rate
averages 1.5–2.0 mL/min while the unstimulated salivary flow rate is approximately
0.3–0.4 mL/min.4,5 A diagnosis of hyposalivation is made when the stimulated salivary
flow rate is #0.5–0.7 mL/min and the unstimulated salivary flow rate is #0.1 mL/min.5–7
Xerostomia in patients with objective hyposalivation is diagnosed when the rate of
saliva flow is less than the rate of fluid absorption across the oral mucosa plus the rate
of fluid evaporation from the mouth.8
Chronic xerostomia remains a significant burden for many individuals. In particular,
it may affect speech, chewing, swallowing, denture-wearing, and general well-being.9
Xerostomia secondary to hyposalivation may also result in rampant dental caries, oral
fungal infections (eg, candidiasis), taste changes, halitosis, or burning mouth.5,10,11
The most frequent cause of hyposalivation is the use of certain medications (such as
anticoagulants, antidepressants, antihypertensives, antiretrovirals, hypoglycemics,
levothyroxine, multivitamins and supplements, non-steroidal anti-inflammatory drugs,
and steroid inhalers) (Villa et al, unpublished data, 2014), followed by radiotherapy
to the head and neck, and Sjögren’s syndrome.12 Other factors include depression,
anxiety and stress, or malnutrition.13
The prevalence of xerostomia in the population ranges from 5.5% to 46%. Studies
have shown differences in the prevalence between the sexes and xerostomia appears
to increase with increasing age. A possible explanation is that older individuals take
several xerogenic drugs for their chronic conditions and this may lead to an overall
reduction of the unstimulated salivary flow rate.1,10,12,14–18 Xerostomia remains an unre-
solved common complaint especially among the geriatric population, despite seeking
medical or dental consultation.19 The aim of this review is to explore the current state
Correspondence: Alessandro Villa
Division of Oral Medicine and Dentistry,
Brigham and Women’s Hospital, 1620
Tremont Street, Suite BC-3-028,
Boston, MA 02120, USA
Tel +1 617 732 5517
Fax +1 617 232 8970
Email avilla@partners.org
Journal name: Therapeutics and Clinical Risk Management
Article Designation: Review
Year: 2015
Volume: 11
Running head verso: Villa et al
Running head recto: Diagnosis and management of xerostomia and hyposalivation
DOI: http://dx.doi.org/10.2147/TCRM.S76282
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Villa et al
of knowledge on management and treatment of patients
affected by xerostomia and hyposalivation.
Diagnosis of xerostomia and salivary
gland hypofunction
The diagnosis of xerostomia and salivary gland hypofunc-
tion requires a thorough medical history. Particular attention
should be given to the reported symptoms, medication use,
and past medical history.
Patients with salivary gland hypofunction typically com-
plain of dry mouth, difficulty swallowing and/or speaking;
they hardly tolerate spicy, acidic, and crunchy food and often
times report taste changes or difficulty wearing dentures.20
Several questionnaires have been proposed to identify
patients with xerostomia and hyposalivation. Fox et al
developed a questionnaire on the severity of dry mouth,
which may predict true hyposalivation (Table 1).21 A positive
answer to all the questions was associated with low saliva
flow rates. A few years later, Thomson et al created an
eleven-item summated rating scale on the severity of chronic
xerostomia (Xerostomia Inventory).22 Each response was
scored and summed to give a final score. van der Putten et al
shortened the Xerostomia Inventory and proposed the Sum-
mated Xerostomia Inventory-Dutch. Only five items were
included.2 In the questionnaire developed by Sreebny and
Valdini, the question “does your mouth usually feel dry” was
found to have had a sensitivity of 93%, a specificity of 68%,
a negative predictive value of 98%, and a positive predictive
value of 54% for hyposalivation.23 Eisbruch et al studied the
grade of xerostomia through a validated scale made of three
Table 1 Questionnaires to assess dry mouth
Authors Questions/statements Response/scoring
Fox et al21 1) Does the amount of saliva in your mouth seem to
be too little, too much, or you do not notice it?
2) Do you have any difculty swallowing?
3) Does your mouth feel dry when eating a meal?
4) Do you sip liquids to aid in swallowing dry food?
Yes/no
Thomson et al22 1) My mouth feels dry
2) I have difculty in eating dry foods
3) I get up at night to drink
4) My mouth feels dry when eating a meal
5) I sip liquids to aid in swallowing food
6) I suck sweets or cough lollies to relieve dry mouth
7) I have difculties swallowing certain foods
8) The skin of my face feels dry
9) My eyes feel dry
10) My lips feel dry
11) The inside of my nose feels dry
Never = scoring 1
Hardly ever = scoring 2
Occasionally = scoring 3
Fairly often = scoring 4
Very often = scoring 5
van der Putten et al21) My mouth feels dry when eating a meal
2) My mouth feels dry
3) I have difculty in eating dry foods
4) I have difculties swallowing certain foods
5) My lips feel dry
Never = scoring 1
Occasionally = scoring 2
Ever = scoring 3
Eisbruch et al24 Subjective grade 1= no disability
Subjective grade 2= dryness requiring additional uids
for swallowing
Subjective grade 3= dryness causing dietary alterations
or interference with sleep, speaking, or other
activities
Not applicable
Pai et al25 1) Rate the difculty you experience in speaking due
to dryness
2) Rate the difculty you experience in swallowing
due to dryness
3) Rate how much saliva is in your mouth
4) Rate the dryness in your mouth
5) Rate the dryness in your throat
6) Rate the dryness of your lips
7) Rate the dryness of your tongue
8) Rate the level of your thirst
100 mm horizontal scale
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47
Diagnosis and management of xerostomia and hyposalivation
grades (Table 1).24 Finally, Pai et al proposed an eight-item
visual analogue scale with which patients were asked to score
their xerostomia.25
One of the major risk factors for xerostomia and hypos-
alivation is the use of certain medications. In addition,
polypharmacy has been shown to significantly influence
patients’ saliva flow.10,26 “Xerogenic” medications associ-
ated with a low unstimulated saliva flow are: psycholeptics,
psychoanaleptics (particularly selective serotonin reuptake
inhibitors), oral antidiabetics (mainly sulfonylureas),
respiratory agents, quinine, antihypertensive agents (such
as thiazides and calcium channel blockers), urinary anti-
spasmodics, glucosamine, non-steroidal anti- inflammatory
drugs, opioids, ophthalmologicals, and magnesium
hydroxide.7,27 Clinicians should review the drug history
carefully in order to identify medications that can reduce
the saliva flow in patients complaining of xerostomia.
Finally, a thorough medical history should be obtained in
order to identify other known causes of xerostomia such
as Sjögren’s syndrome, radiation treatment of the head
and neck region, and other systemic diseases (particularly
hypertension, asthma, diabetes mellitus, hematological
diseases, thyroid diseases, rheumatic diseases, psychiatric
diseases, and eating disorders).
A careful oral examination is fundamental to identify
clinical signs pathognomonic for hyposalivation. Several
helpful signs have been proposed by Osailan et al: 1) sticking
of an intraoral mirror to the buccal mucosa or tongue;
2) frothy saliva; 3) no saliva pooling in floor of mouth;
4) loss of papillae of the tongue dorsum; 5) altered/smooth
gingival architecture; 6) glassy appearance to the oral mucosa
(especially the palate); 7) lobulated/deeply fissured tongue;
8) cervical caries (more than two teeth); and/or 9) mucosal
debris on palate (except under dentures).28
Measurement of salivary ow rates
Most of the methods to measure the salivary flow are easy
to perform and require little time. Salivary flow rates are
usually measured for at least 5 minutes after an overnight
fast or 2 hours after a meal.29 Unstimulated whole salivary
flow rate is assessed with the patient seated in an upright
position. Patients are asked to constantly drain saliva from
the lower lip into a graduated container for 15 minutes
(draining method).30 Leal et al proposed to collect saliva with
preweighed cotton rolls placed at the orifices of the ducts of
the major salivary glands and then reweigh them after the
collection time.14 The saliva can also be collected using a
graduated absorbent strip placed on the floor of the mouth
(readings at 1, 2, and 3 minutes).31 Other methods to assess
the unstimulated whole salivary flow rate include the spitting
method and the suction method.14,30 Stimulated salivary flow
rate is measured after the patient has chewed an unflavored
gum base or paraffin wax (1–2 g) for 1 minute.32 Otherwise,
saliva production can be stimulated with a solution of 2%
citric acid placed on the sides of the tongue at intervals of 30
seconds. The saliva is then collected into a graduated cylinder
for 5 minutes. Salivary flow (both stimulated and unstimu-
lated) can also be measured selectively from one major
salivary gland or minor salivary gland. The parotid gland
secretion is typically collected by using a suction device
and placing a cup (the Lashley or Carlson–Crittenden cup)
over the Stensen duct.33 The submandibular gland salivary
flow rate can be measured by incannulation of the Wharton’s
duct.34 A similar system to measure the salivary flow rates
for both the sublingual and submandibular glands has been
developed by Wolff et al.35 Minor salivary gland salivary flow
can be measured with micropipette and absorbent filter paper
(the Periotron® method; ProFlow™ Inc, Amityville, NY,
USA).36 Flow rates can be calculated in units of μL/min/cm2
of mucosal area.37
Management and treatment of
xerostomia
Several treatment strategies for the management of xeros-
tomia have been proposed in the past years and they all
aim to reduce patients’ symptoms and/or increase salivary
flow. Easy remedies are proper hydration; increase in
humidity at night-time; avoidance of irritating dentifrices
and crunchy/hard foods; and use of sugar-free chewing
gums/candy.38 Medications include mucosal lubricants, saliva
substitutes, and saliva stimulants.
Systemic sialogogues
Pilocarpine and cevimeline are two systemic US Food and
Drug Administration-approved sialogogues for treatment of
dry mouth. Their effect depends on the presence of functional
glandular tissue. Oral pilocarpine is a parasympathomi-
metic medication with muscarinic action.39,40 Cevimeline
is a salivary gland stimulant with a stronger affinity for M3
muscarinic receptors.41–44 Pilocarpine and cevimeline provide
a similar benefit in patients with dry mouth.45 Pilocarpine
is typically administered at a dose of 5 mg three times a
day for at least 3 months and cevimeline is prescribed at
a dose of 30 mg three times a day for at least 3 months.46
Side effects include: excessive sweating, cutaneous vaso-
dilatation, emesis, nausea, diarrhea, persistent hiccup,
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Villa et al
bronchoconstriction, hypotension, bradycardia, increased
urinary frequency, and vision problems. Both pilocarpine
and cevimeline are relatively contraindicated in patients with
uncontrolled asthma or chronic pulmonary disease and in
β-adrenergic blocker users, and should be used with caution
in patients with active gastric ulcers or uncontrolled hyper-
tension. Pilocarpine is also contraindicated in individuals
with narrow-angle glaucoma and iritis, and should be used
with caution in individuals with chronic pulmonary disease,
asthma, or cardiovascular diseases.40
Other sialogogues
Anethole trithione is a cholagogue that has been shown to
improve oral symptoms and increase the salivary flow in
patients with xerostomia and hyposalivation.47 More stud-
ies are necessary to prove the efficacy of this medication.
Patients who were treated with psychotropic drugs (tricyclic
antidepressants or neuroleptics) and were suffering from
xerostomia benefited from yohimbine use, an alpha 2 adre-
noceptor antagonist.48
Intraoral topical agents
Intraoral topical agents are among the most common
recommended treatments for the management of xeros-
tomia. These include chewing gums, saliva stimulants,
and substitutes. A topical sialogogue spray containing 1%
malic acid has recently shown its efficacy in managing
symptoms of xerostomia in patients with antidepressant- or
antihypertensive-induced dry mouth;49,50 however, this has
the potential to cause mild enamel erosion. Commercially
available sugar-free chewing gums and candies can also
be used to simulate salivary flow.51 In particular, chewing
gums have been shown to increase saliva secretion and
decrease oral mucosal friction.52 In addition to chewing
gum, saliva stimulants and substitutes (eg, gel, mouthwash,
and toothpaste) provide over-the-counter alternatives
for salivary gland hypofunction management. Other oral
sprays, specifically oxygenated glycerol tri-ester, serve
as an alternative treatment for dry mouth and have been
proven to be more effective than other commercially avail-
able saliva substitutes.53 Saliva substitutes aim to increase
viscosity and mimic natural saliva without altering the
salivary flow.54 These agents contain minerals (eg, fluoride,
calcium, and phosphate ions), carboxymethylcellulose or
hydroxyethylcellulose, flavoring agents, and preservatives
(eg, propyl or methyl paraben).38 Other efficacious remedies
include mucoadhesive lipid-based bioerodible tablets55 or
mucin spray, although their efficacy for management of
xerostomia remains controversial.51,56–59 Mucin-containing
lozenges provided benefit for the treatment of xerostomia
when compared to a placebo.60 Other topical agents (tooth-
paste, mouth rinse, mouth spray, and gel) containing olive
oil, betaine, and xylitol may be effective in improving
xerostomia secondary to medication use.61 Of note, saliva
substitute spray containing carboxymethylcellulose,62
xanthan gum-containing spray,63 or buffered Profylin gel64
did not seem to improve dry mouth symptoms. Also lemon
lozenge use in individuals with xerostomia did not show
any increase in salivary flow when compared to baseline
paraffin-stimulated mean flow rate and the gum-stimulated
flow rates.65 Of interest, Regelink et al reported that saliva
substitutes are not effective in patients with reasonable
stimulated salivary flow.66
The saliva substitute Saliva Orthana, a mucin-con-
taining oral spray, was tested in a double-blind, single-
phase, placebo-controlled trial for patients complaining of
xerostomia.59 The results of this study did not show any
significant improvement when compared to the placebo.
When oral lubricants are considered, the gel formulation
appears to be the most efficient and appreciated by patients.67
Patients taking oral lozenges of anhydrous crystalline malt-
ose showed an increase in saliva production and a decrease
in perceived symptoms of xerostomia.68 Patients applying
the anticholinesterase physostigmine on the oral mucosa to
stimulate salivary production from the minor glands reported
great benefit, and this could be a valid alternative to systemic
treatment.69
Changes in medications
Although the evidence available is limited, with patients
on medications known to induce salivary gland hypofunc-
tion, a treatment alternative includes decreasing the dosage
of the medications or potentially replacing the medica-
tions with less xerogenic drugs.70 Studies have shown that
xerostomia became more manageable through medication
dose reduction and medication replacement.71,72 Any
change in medication should be discussed with the refer-
ring physician.
Others
Other remedies have been proposed for the management of
xerostomia. Intraoral electrostimulation has also been tested
to increase salivary flow.73,74 Furthermore, reports have
shown that intraoral appliances, such as the saliva stimula-
tion device Saliwell Crown or the electrostimulating device
GenNarino, have been effective in reducing dry mouth and
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49
Diagnosis and management of xerostomia and hyposalivation
increasing the production of saliva.75 Acupuncture may be
a useful adjunct for the stimulation of salivary flow in some
patients with xerostomia and in patients with irradiation-
induced xerostomia. However, additional larger studies are
necessary to confirm these findings.76,77
Finally, patients who undergo radiation of the head and neck
region may benefit from the use of intensity-modified radiation
therapy and/or of amifostine (cytoprotective agent).78
Conclusion
Xerostomia and hyposalivation remain a debilitating con-
dition for many individuals. This review summarizes the
diagnostic and therapeutic approaches to manage xerostomia
and hyposalivation. Clinicians with a patient complaining of
xerostomia have the opportunity to identify patients with true
salivary gland hypofunction with effective diagnostic criteria
and functional tests, and therefore prevent secondary effects.
Although no standard treatment guidelines are available,
many treatment options exist for the management of xeros-
tomia and hyposalivation: topical agents to alleviate and/or
prevent xerostomia, systemic therapy, or newer devices.
While systemic agents such as pilocarpine or cevimeline
have been largely studied, new medical devices require large
well-designed clinical trials.
Disclosure
The authors report no conflicts of interest in this work.
References
1. Hopcraft MS, Tan C. Xerostomia: an update for clinicians. Aust Dent J.
2010;55(3):238–244; quiz 353.
2. van der Putten GJ, Brand HS, Schols JM, de Baat C. The diagnostic
suitability of a xerostomia questionnaire and the association between
xerostomia, hyposalivation and medication use in a group of nursing
home residents. Clin Oral Investig. 2011;15(2):185–192.
3. Fox PC, van der Ven PF, Sonies BC, Weiffenbach JM, Baum BJ.
Xerostomia: evaluation of a symptom with increasing significance.
J Am Dent Assoc. 1985;110(4):519–525.
4. Humphrey SP, Williamson RT. A review of saliva: normal composition,
flow, and function. J Prosthet Dent. 2001;85(2):162–169.
5. Pedersen AM, Bardow A, Jensen SB, Nauntofte B. Saliva and gastroin-
testinal functions of taste, mastication, swallowing and digestion. Oral
Dis. 2002;8(3):117–129.
6. Heintze U, Birkhed D, Björn H. Secretion rate and buffer effect of
resting and stimulated whole saliva as a function of age and sex. Swed
Dent J. 1983;7(6):227–238.
7. Sreebny LM, Vissink A, editors. Dry Mouth: the malevolent symptom.
A clinical guide. Ames: Wiley-Blackwell; 2010.
8. Dawes C. How much saliva is enough for avoidance of xerostomia?
Caries Res. 2004;38(3):236–240.
9. Cassolato SF, Turnbull RS. Xerostomia: clinical aspects and treatment.
Gerodontology. 2003;20(2):64–77.
10. Villa A, Polimeni A, Strohmenger L, Cicciù D, Gherlone E, Abati S.
Dental patients’ self-reports of xerostomia and associated risk factors.
J Am Dent Assoc. 2011;142(7):811–816.
11. Ekström J, Khosravani N, Castagnola M, Messana I. Saliva and the
control of its secretion. In: Ekberg O, editor. Dysphagia: Diagnosis
and Treatment. Berlin: Springer-Verlag; 2012:19–47.
12. Thomson WM. Issues in the epidemiological investigation of dry mouth.
Gerodontology. 2005;22(2):65–76.
13. Bergdahl M, Bergdahl J. Low unstimulated salivary flow and subjec-
tive oral dryness: association with medication, anxiety, depression, and
stress. J Dent Res. 2000;79(9):1652–1658.
14. Leal SC, Bittar J, Portugal A, Falcão DP, Faber J, Zanotta P. Medication
in elderly people: its influence on salivary pattern, signs and symptoms
of dry mouth. Gerodontology. 2010;27(2):129–133.
15. Astor FC, Hanft KL, Ciocon JO. Xerostomia: a prevalent condition in
the elderly. Ear Nose Throat J. 1999;78(7):476–479.
16. Liu B, Dion MR, Jurasic MM, Gibson G, Jones JA. Xerostomia and
salivary hypofunction in vulnerable elders: prevalence and etiol-
ogy. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114(1):
52–60.
17. Locker D. Subjective reports of oral dryness in an older adult popula-
tion. Community Dent Oral Epidemiol. 1993;21(3):165–168.
18. Thorselius I, Emilson CG, Osterberg T. Salivary conditions and drug
consumption in older age groups of elderly Swedish individuals. Gero-
dontics. 1988;4(2):66–70.
19. Nagler RM. Salivary glands and the aging process: mechanistic aspects,
health-status and medicinal-efficacy monitoring. Biogerontology.
2004;5(4):223–233.
20. Valdez IH, Fox PC. Diagnosis and management of salivary dysfunction.
Crit Rev Oral Biol Med. 1993;4(3–4):271–277.
21. Fox PC, Busch KA, Baum BJ. Subjective reports of xerostomia and
objective measures of salivary gland performance. J Am Dent Assoc.
1987;115(4):581–584.
22. Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The Xeros-
tomia Inventory: a multi-item approach to measuring dry mouth. Com-
munity Dent Health. 1999;16(1):12–17.
23. Sreebny LM, Valdini A. Xerostomia. Part I: Relationship to other oral
symptoms and salivary gland hypofunction. Oral Surg Oral Med Oral
Pathol. 1988;66(4):451–458.
24. Eisbruch A, Rhodus N, Rosenthal D, et al. How should we measure
and report radiotherapy-induced xerostomia? Semin Radiat Oncol.
2003;13(3):226–234.
25. Pai S, Ghezzi EM, Ship JA. Development of a Visual Analogue
Scale questionnaire for subjective assessment of salivary dysfunction.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(3):
311–316.
26. Singh ML, Papas A. Oral Implications of Polypharmacy in the Elderly.
Dent Clin North Am. 2014;58(4):783–796.
27. Smidt D, Torpet LA, Nauntofte B, Heegaard KM, Pedersen AM.
Associations between labial and whole salivary flow rates, systemic
diseases and medications in a sample of older people. Community Dent
Oral Epidemiol. 2010;38(5):422–435.
28. Osailan S, Pramanik R, Shirodaria S, Challacombe SJ, Proctor GB.
Investigating the relationship between hyposalivation and mucosal
wetness. Oral Dis. 2011;17(1):109–114.
29. Löfgren CD, Wickström C, Sonesson M, Lagunas PT, Christersson C.
A systematic review of methods to diagnose oral dryness and salivary
gland function. BMC Oral Health. 2012;12:29.
30. Navazesh M. Methods for collecting saliva. Ann N Y Acad Sci. 1993;
694:72–77.
31. Chen A, Wai Y, Lee L, Lake S, Woo SB. Using the modified Schirmer
test to measure mouth dryness: a preliminary study. J Am Dent Assoc.
2005;136(2):164–170; quiz 229–230.
32. Navazesh M, Kumar SK; University of Southern California School of
Dentistry. Measuring salivary flow: challenges and opportunities. J Am
Dent Assoc. 2008;139 Suppl:35S–40S.
33. Lashley KS. Reflex secretion of the human parotid gland. J Exp Psychol.
1916;1(6):461–493.
34. Schneyer LH. Method for the collection of separate submaxillary and
sublingual salivas in man. J Dent Res. 1955;34(2):257–261.
Therapeutics and Clinical Risk Management 2015:11
submit your manuscript | www.dovepress.com
Dovepress
Dovepress
50
Villa et al
35. Wolff A, Begleiter A, Moskona D. A novel system of human
submandibular/sublingual saliva collection. J Dent Res. 1997;76(11):
1782–1786.
36. Eliasson L, Carlén A. An update on minor salivary gland secretions.
Eur J Oral Sci. 2010;118(5):435–442.
37. Smidt D, Torpet LA, Nauntofte B, Heegaard KM, Pedersen AM. Asso-
ciations between oral and ocular dryness, labial and whole salivary flow
rates, systemic diseases and medications in a sample of older people.
Community Dent Oral Epidemiol. 2011;39(3):276–288.
38. Visvanathan V, Nix P. Managing the patient presenting with xerostomia:
a review. Int J Clin Pract. 2010;64(3):404–407.
39. Takakura AC, Moreira TS, Laitano SC, De Luca Júnior LA, Renzi A,
Menani JV. Central muscarinic receptors signal pilocarpine-induced
salivation. J Dent Res. 2003;82(12):993–997.
40. Wiseman LR, Faulds D. Oral pilocarpine: a review of its pharmacologi-
cal properties and clinical potential in xerostomia. Drugs. 1995;49(1):
143–155.
41. Iwabuchi Y, Masuhara T. Sialogogic activities of SNI-2011 compared
with those of pilocarpine and McN-A-343 in rat salivary glands: iden-
tification of a potential therapeutic agent for treatment of Sjorgen’s
syndrome. Gen Pharmacol. 1994;25(1):123–129.
42. Iwabuchi Y, Katagiri M, Masuhara T. Salivary secretion and his-
topathological effects after single administration of the muscarinic
agonist SNI-2011 in MRL/lpr mice. Arch Int Pharmacodyn Ther.
1994;328(3):315–325.
43. Weber J, Keating GM. Cevimeline. Drugs. 2008;68(12):1691–1698.
44. Chambers MS, Jones CU, Biel MA, et al. Open-label, long-term safety
study of cevimeline in the treatment of postirradiation xerostomia. Int
J Radiat Oncol Biol Phys. 2007;69(5):1369–1376.
45. Braga MA, Tarzia O, Bergamaschi CC, Santos FA, Andrade ED,
Groppo FC. Comparison of the effects of pilocarpine and cevimeline
on salivary flow. Int J Dent Hyg. 2009;7(2):126–130.
46. Aframian DJ, Helcer M, Livni D, Robinson SD, Markitziu A, Nadler C.
Pilocarpine treatment in a mixed cohort of xerostomic patients. Oral
Dis. 2007;13(1):88–92.
47. Hamada T, Nakane T, Kimura T, et al. Treatment of xerostomia with
the bile secretion-stimulating drug anethole trithione: a clinical trial.
Am J Med Sci. 1999;318(3):146–151.
48. Bagheri H, Schmitt L, Berlan M, Montastruc JL. A comparative study
of the effects of yohimbine and anetholtrithione on salivary secretion
in depressed patients treated with psychotropic drugs. Eur J Clin
Pharmacol. 1997;52(5):339–342.
49. Gómez-Moreno G, Guardia J, Aguilar-Salvatierra A, Cabrera-Ayala M,
Maté-Sánchez de-Val JE, Calvo-Guirado JL. Effectiveness of malic acid
1% in patients with xerostomia induced by antihypertensive drugs. Med
Oral Patol Oral Cir Bucal. 2013;18(1):e49–e55.
50. Gómez-Moreno G, Aguilar-Salvatierra A, Guardia J, et al. The efficacy
of a topical sialogogue spray containing 1% malic acid in patients with
antidepressant-induced dry mouth: a double-blind, randomized clinical
trial. Depress Anxiety. 2013;30(2):137–142.
51. 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.
52. Olsson H, Spak CJ, Axéll T. The effect of a chewing gum on salivary
secretion, oral mucosal friction, and the feeling of dry mouth in xeros-
tomic patients. Acta Odontol Scand. 1991;49(5):273–279.
53. Mouly SJ, Orler JB, Tillet Y, et al. Efficacy of a new oral lubricant
solution in the management of psychotropic drug-induced xerostomia:
a randomized controlled trial. J Clin Psychopharmacol. 2007;27(5):
437–443.
54. van der Reijden WA, Vissink A, Veerman EC, Amerongen AV. Treat-
ment of oral dryness related complaints (xerostomia) in Sjögren’s
syndrome. Ann Rheum Dis. 1999;58(8):465–474.
55. Aframian DJ, Mizrahi B, Granot I, Domb AJ. Evaluation of a
mucoadhesive lipid-based bioerodable tablet compared with Biotène
mouthwash for dry mouth relief – a pilot study. Quintessence Int.
2010;41(3):e36–e42.
56. Blixt-Johansen G, Ek AC, Ganowiak W, et al. Improvement of oral
mucosa with mucin containing artificial saliva in geriatric patients. Arch
Gerontol Geriatr. 1992;14(2):193–201.
57. Duxbury AJ, Thakker NS, Wastell DG. A double-blind cross-over trial of
a mucin-containing artificial saliva. Br Dent J. 1989;166(4):115–120.
58. van der Reijden WA, van der Kwaak H, Vissink A, Veerman EC,
Amerongen AV. Treatment of xerostomia with polymer-based saliva sub-
stitutes in patients with Sjögren’s syndrome. Arthritis Rheum. 1996;39(1):
57–63.
59. Sweeney MP, Bagg J, Baxter WP, Aitchison TC. Clinical trial of a
mucin-containing oral spray for treatment of xerostomia in hospice
patients. Palliat Med. 1997;11(3):225–232.
60. Gravenmade EJ, Vissink A. Mucin-containing lozenges in the treatment
of intraoral problems associated with Sjögren’s syndrome. A double-
blind crossover study in 42 patients. Oral Surg Oral Med Oral Pathol.
1993;75(4):466–471.
61. Ship JA, McCutcheon JA, Spivakovsky S, Kerr AR. Safety and effec-
tiveness of topical dry mouth products containing olive oil, betaine, and
xylitol in reducing xerostomia for polypharmacy-induced dry mouth.
J Oral Rehabil. 2007;34(10):724–732.
62. Donatsky O, Johnsen T, Holmstrup P, Bertram U. Effect of Saliment on
parotid salivary gland secretion and on xerostomia caused by Sjögren’s
syndrome. Scand J Dent Res. 1982;90(2):157–162.
63. Jellema AP, Langendijk H, Bergenhenegouwen L, et al. The effi-
cacy of Xialine in patients with xerostomia resulting from radio-
therapy for head and neck cancer: a pilot-study. Radiother Oncol.
2001;59(2):157–160.
64. Persson A, Lingström P, Bergdahl M, Claesson R, van Dijken JW. Buff-
ering effect of a prophylactic gel on dental plaque in institutionalised
elderly. Gerodontology. 2007;24(2):98–104.
65. Stewart CM, Jones AC, Bates RE, Sandow P, Pink F, Stillwell J.
Comparison between saliva stimulants and a saliva substitute in
patients with xerostomia and hyposalivation. Spec Care Dentist.
1998;18(4):142–148.
66. Regelink G, Vissink A, Reintsema H, Nauta JM. Efficacy of a
synthetic polymer saliva substitute in reducing oral complaints of
patients suffering from irradiation-induced xerostomia. Quintessence Int.
1998;29(6):383–388.
67. Furumoto EK, Barker GJ, Carter-Hanson C, Barker BF. Subjective and
clinical evaluation of oral lubricants in xerostomic patients. Spec Care
Dentist. 1998;18(3):113–118.
68. Fox PC, Cummins MJ, Cummins JM. Use of orally administered anhy-
drous crystalline maltose for relief of dry mouth. J Altern Complement
Med. 2001;7(1):33–43.
69. Khosravani N, Birkhed D, Ekström J. The cholinesterase inhibitor
physostigmine for the local treatment of dry mouth: a randomized
study. Eur J Oral Sci. 2009;117:209–217.
70. Sreebny LM, Valdini A. Xerostomia. A neglected symptom. Arch Intern
Med. 1987;147(7):1333–1337.
71. Azodo CC, Ezeja EB, Omoaregba JO, James BO. Oral health
of psychiatric patients: the nurse’s perspective. Int J Dent Hyg.
2012;10(4):245–249.
72. Trindade E, Menon D, Topfer LA, Coloma C. Adverse effects associated
with selective serotonin reuptake inhibitors and tricyclic antidepres-
sants: a meta-analysis. CMAJ. 1998;159(10):1245–1252.
73. Strietzel FP, Lafaurie GI, Mendoza GR, et al. Efficacy and safety of an
intraoral electrostimulation device for xerostomia relief: a multicenter,
randomized trial. Arthritis Rheum. 2011;63(1):180–190.
74. Strietzel FP, Martin-Granizo R, Fedele S, et al. Electrostimulating device
in the management of xerostomia. Oral Dis. 2007;13(2):206–213.
75. Alajbeg I, Falcão DP, Tran SD, et al. Intraoral electrostimulator
for xerostomia relief: a long-term, multicenter, open-label, uncon-
trolled, clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol.
2012;113(6):773–781.
76. Blom M, Dawidson I, Angmar-Månsson B. The effect of acupuncture
on salivary flow rates in patients with xerostomia. Oral Surg Oral Med
Oral Pathol. 1992;73(3):293–298.
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Diagnosis and management of xerostomia and hyposalivation
77. O’Sullivan EM, Higginson IJ. Clinical effectiveness and safety of
acupuncture in the treatment of irradiation-induced xerostomia in
patients with head and neck cancer: a systematic review. Acupunct
Med. 2010;28(4):191–199.
78. Gu J, Zhu S, Li X, Wu H, Li Y, Hua F. Effect of amifostine in head
and neck cancer patients treated with radiotherapy: a systematic review
and meta-analysis based on randomized controlled trials. PLoS One.
2014;9(5):e95968.
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