Background. The objective of this literature
review is to summarize information about the eti-
ology, diagnosis, oral sequelae and treatment of dry
mouth in elderly patients.
Types of Studies Reviewed. The authors con-
ducted a comprehensive review of the English-based scientific literature
from the past 10 years. They selected the studies on the basis of
clinical investigations to provide an objective assessment of dry mouth
problems among older people.
Results. Dry mouth (salivary hypofunction, xerostomia) is a common
problem among older people. It causes significant oropharyngeal disorders,
pain and an impaired quality of life. Dry mouth has many causes, from
local salivary disorders to a plethora of medications and medical condi-
tions. Treatments are designed to correct the underlying cause and/or to
enhance salivation with topical and systemic stimulants. Early interven-
tion for dry mouth problems helps prevent the deleterious consequences of
this disorder in elderly people.
Clinical Implications. Clinicians must be aware of dry mouth prob-
lems in older patients, and they should be prepared to provide a diagnosis
and administer treatment to protect a patient’s oropharyngeal health and
quality of life.
Key Words. Xerostomia; aging; saliva; salivary glands; Sjögren’s
syndrome; cancer; radiotherapy; medications.
JADA 2007;138(9 supplement):15S-20S.
S
aliva plays a critical role
in the preservation of
oropharyngeal health.
Complaints of a dry
mouth (xerostomia) and
diminished salivary output are

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Dr. Turner is an assistant professor, Department of Oral and Maxillofacial Surgery, New York University
College of Dentistry, New York City.
Dr. Ship is a professor, Department of Oral and Maxillofacial Pathology, Radiology, and Medicine, New
York University College of Dentistry; a professor, Department of Medicine, New York University School
of Medicine; and director, Bluestone Center for Clinical Research, New York University College of
Dentistry, 421 First Ave., 2nd Floor, New York, N.Y. 10010-4086, e-mail “”.
Address reprint requests to Dr. Ship.
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Dry mouth in elderly people. Many older
adults experience dry mouth for a variety of rea-
sons.
4,5
Interestingly, output from the major sali-
vary glands does not undergo clinically significant
decrements in healthy older people.
6
Some data
show age-related changes in salivary con-
stituents, but other evidence shows
age-stable production of salivary
electrolytes and proteins in the
absence of major medical problems
and medication use. Clinicians
should not attribute complaints of a
dry mouth and findings of salivary
hypofunction in an older person to
his or her age; an appropriate diag-
nosis is required.
Salivary disorders in the aging
population usually are caused by
systemic diseases and their treat-
ments (for example, anticholinergic medications or
radiation therapy). Numerous medical conditions
(such as SS, diabetes, Alzheimer’s disease, dehy-
dration), medications (both prescription and non-
prescription), head and neck irradiation and
chemotherapy can cause or contribute to salivary
gland diseases.

salivary output. Common categories of these
drugs include tricyclic antidepressants, sedatives
and tranquilizers; antihistamines; antihyperten-
sives (α and β blockers, diuretics, calcium channel
blockers, angiotensin-converting enzyme
inhibitors); cytotoxic agents; and anti-
Parkinsonism and antiseizure drugs.
Chemotherapeutic agents also have been asso-
ciated with salivary disorders.
11
After completing
therapy, most patients experience a return of sali-
vary function to prechemotherapy
levels; however, long-term changes
in salivary function have been
reported.
12
Radioactive iodine
(I-131), which is used to treat thy-
roid malignancies, damages sali-
vary tissues in a dose-dependent
fashion, primarily affecting the
parotid glands.
5,13
Radiation therapy. A common
therapy for head and neck cancers
is external beam radiation, which
causes severe and permanent sali-
vary hypofunction and results in persistent com-
plaints of xerostomia.

Syndrome A autoantibodies. SS: Sjögren’s syndrome.
Copyright ©2007 American Dental Association. All rights reserved.
forms. Patients with primary SS have salivary
and lacrimal gland involvement, with an asso-
ciated decreased production of saliva and tears.
In secondary SS, the disorder occurs with other
autoimmune diseases, such as rheumatoid
arthritis, systemic lupus erythematosus, sclero-
derma, polymyositis and polyarteritis nodosa.
2,15
The onset of the disease often is insidious;
accordingly, diagnosis may be delayed for many
years. The female-to-male ratio has been esti-
mated to be 9:1, although reported ratios vary
considerably. The prevalence of primary SS
varies from 0.05 to 4.8 percent,
16
with approxi-
mately 1 million people in the United States esti-
mated to have the disease.
The pathogenesis of SS remains unclear.
2
Environmental agents (for example, viruses) may
trigger events in a genetically susceptible host.
Hormonal factors may play a role in the patho-
genesis, because SS occurs predominantly in
women. SS probably has a genetic component,
because SS autoantibodies (for example, anti-
Ro/Sjögren’s Syndrome A autoantibodies [anti-
Ro/SSA]) are higher in family members of

and extraoral disorders can develop (Figure 1).
Patients with salivary hypofunction experience
numerous oral symptoms. Nighttime xerostomia
is common in these patients, because salivary
output typically reaches its lowest circadian
levels during sleep, and the problem may be exac-
erbated by mouth breathing. Taste may be dis-
turbed, as saliva stimulates gustatory receptors
located on the taste buds and delivers tastants
directly to the taste buds. Patients with chronic
xerostomia secondary to SS, head and neck radio-
therapy and other conditions experience a dimin-
ished ability to detect and recognize many gusta-
tory stimuli.
20
Saliva also is necessary to prepare food for
digestion and deglutition. Patients with low sali-
vary flow have difficulty masticating and swal-
lowing, particularly dry foods, and they may need
liquids to swallow food (Box). These problems can
lead to changes in food and fluid selection that
may compromise nutritional status. They also can
lead to an increased susceptibility to aspiration
pneumonia, with consequent colonization of the
lungs with gram-negative anaerobes from the gin-
gival sulcus.
21
Dentures. The lack of saliva and lubrication in
the denture-mucosal interface can produce den-
ture sores, and retention of prostheses may be

pharynx) become desiccated and friable. The sub-
sequent speech and eating difficulties that may
develop can impair social interactions and may
cause some patients to avoid social engagements.
Patients with salivary hypofunction are more
susceptible to developing mucosal candidiasis,
which can present with a pseudomembrane, ery-
thema of the underlying tissues and/or a burning
sensation of the tongue or other intraoral soft tis-
sues (Figure 2). Fungus-associated denture stom-
atitis usually is diagnosed on the basis of clinical
findings, although microscopy can confirm the
clinical diagnosis via the observation of mycelia
or pseudohyphae in a direct smear. Candida may
colonize the corners of the mouth extraorally
(angular cheilitis) in the areas where the lips are
cracked and dry.
Dental caries. A second frequently occurring
infection is new and recurrent dental caries
(Figure 3). This condition is particularly common
among older adults, many of whom now have
more retained natural teeth, a high number of
previously restored dental surfaces and gingival
recession predisposing teeth to root-surface
caries. Without sufficient saliva to restore the
oral pH and regulate bacterial populations, the
mouth is colonized rapidly with caries-associated
microorganisms.
Visible and palpable enlarged major salivary
glands develop if salivary glands are infected or

rough.
For patients with remaining viable salivary
gland tissue, stimulation techniques are helpful.
Sugar-free chewing gum, candies and mints can
stimulate salivary output. The U.S. Food and
Drug Administration has approved two
18S JADA, Vol. 138 September 2007
Figure 2. Pseudomembraneous candidiasis plaques on the tongue
of a patient with salivary hypofunction and xerostomia.
Figure 3. New and recurrent dental caries in a patient who
received head and neck radiotherapy for a squamous cell carcinoma
of the tongue. The patient experienced permanent loss of salivary
function and xerostomia.
Copyright ©2007 American Dental Association. All rights reserved.
secretagogues, pilo-
carpine
25,26
and
cevimeline,
27,28
for the
treatment of xero-
stomia and salivary
hypofunction. These
drugs are effective in
increasing secretions
and diminishing
xerostomic complaints
in patients with suffi-
cient exocrine tissue.

therapy (for example, ketoconazole, fluconazole)
should be reserved for refractory disease and for
patients who are immunocompromised. Dentures
may harbor fungal infections and thus require
immersion once or twice daily in solutions con-
taining benzoic acid, 0.12 percent chlorhexidine
or 1 percent sodium hypochlorite. Daily denture
hygiene and use of topical antifungal ointment
also are helpful. Clinicians should treat patients
who have angular cheilitis with a combination of
antifungal and anti-inflammatory agents.
Drug substitutions may help reduce the
adverse side effects of medications that produce
xerostomia if similar drugs are available that
have fewer xerostomic side effects. For example,
Scully
29
reported that selective serotonin reuptake
inhibitors cause less dry mouth than do tricyclic
antidepressants.
If an older patient can take anticholinergic
medications during the daytime, nocturnal xero-
stomia can be diminished, because salivary
output is lowest at night.
8
In addition, if a patient
JADA, Vol. 138 September 2007 19S
TABLE
Treatment of xerostomia-associated problems.*
XEROSTOMIA-ASSOCIATED

dCareful eating, with fluids
dCopious use of fluids during meals
dAvoidance of dry, hard, sticky and difficult-to-
masticate foods
dAntifungal rinses: nystatin oral suspension
(100,000 units/milliliter), rinse four times per day
dAntifungal ointments: nystatin ointment applied
four times per day
dAntifungal lozenges dissolved in mouth four times
per day, nystatin pastilles (200,000 units),
clotrimazole troches (10 mg), nystatin vaginal
suppositories
dDenture antifungal treatment (daily hygiene): soak
prosthesis for 30 minutes in benzoic acid,
0.12 percent chlorhexidine or 1 percent sodium
hypochlorite
dSystemic antibiotic therapy for 10 days: amoxicillin
with clavulanate (500 mg every eight hours);
clindamycin (300 mg three times per day);
cephalexin (500 mg every six hours)
dIncrease in hydration
dSalivary stimulation with sugar-free gums, mints,
lozenges
dSoft- and hard-tissue relines by dentist
dUse of denture adhesives
Copyright ©2007 American Dental Association. All rights reserved.
can divide his or her drug dosages, he or she may
be able to avoid the side effects caused by a large
single dose. A dentist’s scrutiny of drug side
effects can assist in diminishing the xerostomic

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lowing I-131 therapy for thyroid carcinoma: concise communication.
J Nucl Med 1984;25(7):755-8.
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volume, and function relationships in parotid salivary glands following
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20S JADA, Vol. 138 September 2007
Copyright ©2007 American Dental Association. All rights reserved.