Xerostomia: A Neglected Burden in Oral Health

Xerostomia (the subjective feeling of dry mouth) arises from reduced or absent saliva flow. It is very common – population studies report prevalence anywhere from ~20% up to 50% or more in older groups – yet it is often overlooked. Patients may experience burning mouth, altered taste, difficulty chewing or swallowing, and oral soreness, but because xerostomia is a symptom rather than a disease, it has historically received too little attention in healthcare. Indeed, oral medicine experts have long warned that “oral health has been described as a neglected area of health management” and that patients with dry mouth often feel their concerns are disregarded. This review highlights how xerostomia affects diverse groups (especially the elderly, oncology patients, and those on chronic medications), examines why it is under-recognized, and underscores the critical role dentists must play in early detection, diagnosis, and management of this condition.

Etiology and Pathophysiology

Xerostomia has many causes. Medications are among the most common – drugs with anticholinergic effects (e.g. antidepressants, antihistamines, blood pressure medications, and many others) inhibit salivary gland function. In fact, anticholinergic medications can induce dry mouth in 17–54% of users and account for ~40% of drug discontinuations in some patient groups. Cancer therapy is another leading cause: radiation to the head and neck destroys salivary gland tissue, producing acute and chronic xerostomia in the majority of patients. Conventional (2D) radiotherapy causes moderate-to-severe dry mouth in about two-thirds of patients, and even newer techniques like IMRT significantly reduce but do not eliminate this effect. Other medical conditions – such as Sjögren’s syndrome, diabetes, or neurological disorders – can also attack salivary glands. In addition, age itself is a factor: older adults often have reduced salivary flow and are more likely to take xerogenic medications. In sum, any drug or disease that impairs the muscarinic stimulation or glandular health of saliva production can lead to xerostomia.

Regardless of cause, xerostomia disrupts oral homeostasis. Saliva normally lubricates the mouth, buffers acids, and provides antimicrobial action. Without adequate saliva, patients suffer oral complications: food lodges in the mouth, swallowing becomes difficult, and taste is dulled. The literature notes that xerostomia “can raise the risk of dental cavities, periodontal diseases, and oral infections such as candidiasis.”. In practical terms, dentists see rapidly progressing tooth decay, cracked or ulcerated mucosa, and frequent oral thrush in dry-mouth patients. Denture wearers often cannot tolerate their prostheses due to lack of suction and lubrication. All of these sequelae increase with longer duration of xerostomia. Thus, although saliva reduction might seem minor, its consequences for oral health and nutrition are significant.

Impact on Patient Populations

Xerostomia is especially prevalent and debilitating in certain segments of the population:

• Elderly and General Adults: Population surveys find a high burden in older people. In one Saudi cross-sectional study, 42.3% of the general adult sample reported dry mouth, with prevalence rising sharply in older age groups. Another study of older hypertensive patients found 51.8% had xerostomia (51.8% vs. 38.1% unstimulated hyposalivation). Women and those with multiple health issues were more likely to be affected. Polypharmacy is common among elders, and one survey of older patients noted that hypertension patients on multiple medications had very high xerostomia rates. In practical terms, many seniors report dry mouth daily – far more than dentists might assume – which can severely impair chewing and speaking.
• Cancer Patients and Palliative Care: Head and neck cancer survivors illustrate the extreme impact. Radiation to the salivary glands typically causes lifelong dryness; older studies show about 66% or more suffer moderate-to-severe xerostomia after conventional radiotherapy. Although modern IMRT has reduced this by ~70%, many patients still endure chronic dry mouth. In palliative populations (mostly advanced cancer), xerostomia is nearly universal: a recent qualitative study found perceived dry mouth in 70–90% of terminal patients. Patients in that study described profound physical and psychological effects: it disrupted sleeping, eating, speaking, and even communication, causing great distress. In fact, the authors concluded that xerostomia had a “profound impact on the daily lives” of palliative patients, especially by impairing speech, and they called for greater awareness and better management. These findings underscore how catastrophic untreated xerostomia can be in cancer care: one comprehensive review notes “the high prevalence of post-treatment xerostomia in cancer patients” and the lack of approved therapies, recommending that care teams (including dentists) pay more attention to it.
• Medication Users (Polypharmacy): Beyond anticancer drugs, many common medications cause dry mouth. Antidepressants, antihistamines, diuretics, opioids, and many other classes each list xerostomia as a side effect. One Japanese clinic study of 490 patients with medication-induced dry mouth reported that about 75% improved with specific treatment, implying the condition is very common among patients on medications. Importantly, the study highlighted that patients on psychiatric drugs or many anticholinergics had lower rates of improvement. This reflects that psychotropic polypharmacy both causes xerostomia and complicates its relief. The World Health Organization and others warn that polypharmacy (taking ≥5 drugs) greatly increases xerostomia risk, with some estimates as high as 80% of older polypharmacy patients affected. These patients often have co-morbidities (e.g. asthma, neuropsychiatric conditions) that further exacerbate dryness. In short, xerostomia is endemic in any group taking multiple medications – a common situation in modern medicine.

Each of these at-risk populations experiences more severe consequences of dry mouth. Even in the general population, studies show xerostomia worsens oral health-related quality of life. In one geriatric cohort, those with xerostomia had significantly higher OHIP-14 impact scores (worse perceived oral health) than those without. The polymedicated-patient study found a direct correlation between xerostomia severity and poorer OHIP-14 scores. Patients complain of difficulty swallowing, burning pain, inability to enjoy food, and embarrassment in social settings. These impacts have been repeatedly documented: as one cancer care review noted, dryness can undermine “comfort” and even undermine basic communication. Because saliva affects taste, appetite and digestion, xerostomia can lead to nutritional problems as well. In summary, while dry mouth may appear a benign symptom, its cumulative impact on health and well-being – especially in vulnerable groups – is profound.

Why Xerostomia is Overlooked

Given its prevalence and impact, why is xerostomia so neglected? Part of the problem is awareness. Surveys of dental professionals reveal significant gaps. For example, one 2024 international study found only about one-third of dentists had “good knowledge” of dry mouth and its management. Many dentists rated themselves only moderately informed. Similarly, a Swedish survey reported that dentists asked about dry mouth far less often than hygienists did, especially in younger adults. Dentists in that study also measured saliva flow rates only half as often as hygienists and recommended preventive visits less frequently. In short, dental teams routinely underestimate xerostomia: they may inquire about it primarily in elderly patients, neglecting younger adults on medications. One review bluntly notes that oral health (including saliva levels) “has been linked with increased mortality” yet remains a sideline in training.

This lack of attention is partly cultural: xerostomia is a symptom without dramatic signs (unlike a cavity or tumor), so it is easy to overlook during exams. Patients themselves may not volunteer that they have dry mouth, or may think it is a normal consequence of aging or illness. When they do complain, clinicians can miss it if they rely only on physical tests – one report cautions that “if objective tests do not align with a patient’s complaints, [they] may feel their symptoms are not being taken seriously”. In practice, many patients with subjective dryness have only modest hyposalivation on measurement, so dentists might dismiss the issue. Moreover, dry mouth is not included in many standard dental screening guidelines, so it lacks routine prompts. The bottom line is that routine dental care often fails to screen for or address xerostomia, relegating it to a footnote despite its proven harms.

The Dentist’s Role: Early Detection and Management

Given how common and consequential xerostomia is, dentists must take the lead. First, dental professionals should screen all patients for dry mouth symptoms. Even young adults on daily medications should be asked about oral dryness. A recent Swedish study emphasizes: “it is important to inquire about oral dryness in all patients, irrespective of age”. Dentists should routinely ask about dry mouth and not assume it occurs only in the elderly. When a patient reports dryness, the dentist can perform simple tests (e.g. Saxon test or sialometry) to confirm hyposalivation, and should consider underlying causes (polypharmacy, Sjögren’s, etc.). Reviewing the patient’s medication list is essential, as stopping or substituting a xerogenic drug may be possible.

Second, dentists should educate patients. Patients often feel ignored, so a dentist can validate the complaint and explain why saliva is important. Basic advice – drink water often, chew sugar-free gum, avoid caffeine/alcohol, practice good oral hygiene – goes a long way. Almost all dental professionals recognize these measures; in one survey, 97% recommended saliva stimulants (like sugar-free gum) and 95% stressed meticulous oral hygiene. Nearly 90% also advise extra topical fluoride. Dentists should provide such preventive care: prescribe high-fluoride toothpaste or varnish to counteract the increased caries risk in dry mouths, and schedule more frequent checkups. In short, the first line of management is symptomatic relief and prevention.

Third, dentists can prescribe or coordinate specific treatments. Pilocarpine or cevimeline (muscarinic agonists) can stimulate saliva and are FDA-approved for certain cases. Novel formulations (e.g. pilocarpine mouthwash) are being studied. Artificial saliva products (gels or sprays) and saliva substitutes can relieve symptoms. For patients with head/neck radiation, advanced therapies (acupuncture, low-level laser, etc.) may be considered under specialty care. Dentists can also collaborate with physicians: for example, a doctor might alter a xerogenic medication or address autoimmune causes. As one review urges, clinicians (including dentists) “should be skilled at recognizing serious cases of xerostomia and implementing appropriate management strategies tailored to individual patient needs.”.

Finally, dentists must advocate for awareness. The evidence suggests that continuing education is key: the international survey found that attendance at dry-mouth education courses predicted better knowledge among dentists. Dental schools and associations should emphasize xerostomia in curricula and clinical exams. In practice, if every dentist viewed dry mouth as a routine vital sign (like blood pressure), the condition would no longer be so overlooked. Integrating screening questions and documentation for xerostomia into dental records can help, as can interdisciplinary conferences for head and neck cancer care. The oncology literature calls for “collaborative efforts” involving dentists and oncologists to manage cancer-related dry mouth – a model that could be extended to other at-risk groups.

Management Strategies

Management of xerostomia is largely palliative but important. General measures include sipping water frequently, using lip balm and humidifiers, avoiding mouth-drying foods (e.g. salty or spicy) and habits (smoking), and using alcohol-free mouthwash. Dentists often recommend products like Biotène or SaliDrops for lubrication. Sialogogues – substances that stimulate saliva – include sugar-free lemon lozenges or chewing gums (sugar-free) to mechanically induce flow. In-office therapies such as topical fluoride gels (0.42% sodium fluoride) help protect enamel in vulnerable patients. Prescription medications (e.g. pilocarpine 5 mg TID) are used for more severe cases, especially when caused by systemic disease or radiation. A 2023 study found that tailored treatment (including oral lubricants, gland massage, and medications) improved xerostomia in about 75% of patients, though those on multiple anticholinergics improved less.

New research is exploring advanced solutions: for instance, stem-cell therapies and gene therapy to restore salivary gland function are under investigation (not yet clinical). But most current treatments remain supportive. The key is early and aggressive intervention: once significant tooth decay or fungal infection has occurred, management becomes much harder. Dentists should therefore not wait for cavities to develop. By combining preventative measures (fluoride, hygiene, diet) with symptom relief, dental teams can minimize the damage from dry mouth. Even small increases in resting saliva can greatly improve comfort and reduce complications.

Conclusion

Xerostomia is far more than a minor inconvenience; it is a critical oral health issue that cuts across all patient populations, especially the elderly, those on medications, and cancer survivors. Yet it remains under-recognized in routine dental practice. Dentists must act as first responders for dry mouth. This means asking every patient about oral dryness, understanding the multiple medical causes, and aggressively managing the condition and its consequences. Dental professionals should embrace this responsibility – as one review puts it, treating xerostomia includes “identifying the possible causes, relieving discomfort, and preventing complications”. With the aging population and growing medication use, the need is only increasing. By heightening awareness and education (among dentists and patients alike), and by applying both simple and advanced therapies, the profession can dramatically improve the quality of life for countless patients. In short, xerostomia deserves no more neglect; timely dental intervention can make all the difference.

Works Cited

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