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Thoracic outlet syndrome can be described compression of the neurovascular structures as they exit through the thoracic outlet (cervicothoracobrachial region). It is a condition in which there is compression of the nerves, arteries, or veins in the passageway from the lower neck to the armpit. The neurogenic type is the most common and presents with pain, weakness, and occasionally loss of muscle at the base of the thumb. The venous type results in swelling, pain, and possibly a bluish coloration of the arm.The arterial type results in pain, coldness, and paleness of the arm The thoracic outlet is marked by the anterior scalene muscle anteriorly, the middle scalene posteriorly, and the first rib inferiorly.

Thoracic outlet syndrome covers a wide range of manifestations due to compression of nerves and vessels during their passage through the cervicothoracobrachial region. Various forms of TOS are distinguished: vascular forms (arterial or venous) which raise few diagnostic problems [Rx], and “neurological” forms, which are by far the most frequent as they represent more than 95% of all cases of TOS [Rx, Rx]. The “neurological forms” are classified in the “true” neurological form associated with neurological deficits (mostly muscular atrophy), and painful neurological forms (with no objective neurological deficit). These painful forms are very frequent, especially when patients are systematically screened for these symptoms. The existence of these forms of TOS remains controversial in part because muscular and neurological manifestations are strongly interrelated. Clinical experience suggests that the main triggering mechanism is more often a muscular dysfunction in the cervicoscapular region than primitive nerve compression. It is directly responsible for cervicoscapular symptoms (pain and discomfort) and sometimes for referred scapulobrachial and facial pain. In parallel, shortened muscles (mainly scalene muscles) and cervicoscapular muscles imbalance may lead to intermittent nerve compression and/or tension on brachial plexus in the thoracic outlet resulting in proximal pain and producing pain and discomfort in the upper limb. The neurological involvement accounts for most of the distal symptoms, but the controversy concerning the reality of TOS is essentially due to the absence of objective criteria to confirm the diagnosis (no neurological weakness and normal neurophysiological examination). Despite considered as “debatable” for some authors, several arguments support the reality of this syndrome, such as the influence of TOS on the results of treatment of carpal tunnel and cubital tunnel syndromes [Rx,Rx]. This problem is further complicated by the frequent concomitant presence of other neuromuscular diseases of the upper limb, which can be secondary to TOS or, on the contrary, may precede and predispose to the development of TOS [Rx, Rx], in which case TOS is often masked by the concomitant disease. “Neurological” forms of TOS can be subdivided into primary forms in which features of TOS may remain isolated or may be complicated by underlying neuromuscular disorders, and forms secondary to a more distal disease (neuromuscular or joint disease), always responsible for complex clinical features.

Types of Thoracic Outlet Syndrome

1. Vascular – This can be a compression of the artery and vein.
2. Neurogenic – The nerves become compromised from an extra cervical rib, present at birth.
3. Disputed or painful form –There is no neurological deficit but patients experience neurological symptoms and pain. Typically these patients’ electrodiagnostic studies (EMG / NCV) are normal, but they complain of pain.

The subtypes include

• Arterial TOS (A-TOS) – due to compression of the subclavian artery, most commonly caused by a cervical rib. Symptoms may include blood clots, arm pain with exertion, or acute arterial thrombosis (sudden blood flow obstruction in an artery).
• Venous TOS (V-TOS) – due to compression of the subclavian vein, often associated with repetitive arm activities. It may cause pain, swelling, and deep vein thrombosis.
• Traumatic neurovascular TOS – occurs after trauma to the collarbone and may affect both nerves and vessels. Symptoms may include pain, swelling, bruising, weakness, and loss of sensation in the arm and hand.
• True neurogenic TOS (TN-TOS) – caused by compression of the brachial plexus. Symptoms include numbness, abnormal sensations, and weakness of the arms and shoulders, as well as pain in the neck, shoulder or hand.
• Disputed TOS – the vast majority of neurogenic cases. It is controversial whether it is a true form of TOS because it lacks a consistent physical abnormality, a recognized cause, consistent symptoms, a reliable method of testing, and a standard treatment. Pain and tingling or numbness in the neck, arm and hand are common complaints..

Anatomy of Thoracic Outlet Syndrome

Thoracic outlet

• Comprised of three distinct spaces  
• Interscalene triangle
• Proximal space

Borders

• Anterior: anterior scalene muscle
• Posterior: middle scalene muscle
• Inferior: first rib

Contents

• Brachial plexus trunks
• Subclavian artery

• Subclavian vein does not pass through interscalene triangle
  • runs beneath anterior scalene muscle prior to entering the costoclavicular space

Costoclavicular space

• Middle space
• Separated from the interscalene triangle by the first rib

Borders

• anterior: clavicle and subclavius muscle
• posterior: first rib and scalene muscles
• medial: costoclavicular ligament
• lateral: upper scapular border

Contents

• Brachial plexus divisions
• Subclavian artery and vein

Retropectoralis minor space

• Distal space

• Also known as the thoraco-coraco-pectoral space or subcoracoid space
• Borders
  • superior: coracoid
  • anterior: pectoralis minor muscle
  • posterior: ribs 2-4

Thoracic Outlet Syndrome

• Brachial plexus cords

• Axillary artery and vein

Causes of Thoracic Outlet Syndrome

TOS can be attributed to one or more of the following factors

• Congenital abnormalities – are often reported and can be associated with traumatic or functional causes. Bone anomalies (cervical rib, prolonged transverse process), fibrous anomalies (transversocostal, costocostal, etc.), or muscular anomalies (scalenus anticus muscle, sickle-shaped scalenus medius, etc.) are more frequent in patients who develop TOS [Rx]. Bone anomalies are well known, but 2/3 of the abnormalities detected at operation are fibromuscular [Rx] and the majority of bone anomalies do not cause TOS [Rx, Rx]. These anomalies are part of a real local and regional “dysplasia” constituting only one of the numerous predisposing factors, associated with a morphotype composed of narrow, drooping shoulders.

Congenital factors

• Cervical rib
• Prolonged transverse process
• Anomalous muscles
•  Fibrous anomalies (transverse costal, costocostal)
•  Abnormalities of the insertion of the scalene muscles
•  Fibrous muscular bands
•  Exostosis of the first rib
•  Cervicodorsal scoliosis
•  Congenital uni- or bilateral elevated scapula
•  Location of the A. or V. Subclavian in relation to the M. scalene anterior

Post-traumatic causes-  either due to isolated trauma or repeated trauma, account for up to 2/3 of cases in some series [Rx, Rx]. Post-traumatic TOS due to soft tissue injury raises medicolegal and often management problems. These forms are related to neck and shoulder trauma, particularly “whiplash” injuries, or sometimes upper limb trauma. Injuries to scalene muscles and their subsequent fibrosis are implicated in this process [Rx, Rx]. Diagnostic criteria of post-traumatic TOS are the pathogenic mechanism and the onset of symptoms within the first two years.

• Functional acquired – causes are the most controversial, although probably the most frequent. In this group, upper limb dysfunction or a muscle imbalance of the neck and shoulder region is considered to be responsible [Rx, Rx]. Two main features are mainly associated with “functional” acquired causes: “hypertrophic” muscle morphotype of the cervicoscapular region and “dropped” scapular morphotype (leading in some patients to a dysfunction of the normal scalenus anterior muscle). Muscles of the thoracic outlet are also accessory respiratory muscles capable of prolonged tonic contractions due to their high percentage of type I muscle fibres [Rx]. Chronic stimulation of these muscles has also been shown to increase the percentage of type I fibres. Machleder showed that a normal scalenus anterior muscle contains 70% of type I fibres versus 85% in the case of TOS [Rx]. The factors involved in the pathogenesis of these disorders include overuse and physical and mental stress phenomena, frequently associated with unfavourable psychosocial factors [Rx
• Postural factors
• Dropped shoulder condition
• Wrong work posture (standing or sitting without paying attention to the physiological curvature of the spine
• Heavy mammaries
• Trauma
• Clavicle fracture
• Rib fracture
• Hyperextension neck injury, whiplash
• Repetitive stress injuries (repetitive injury most often form sitting at a keyboard for long hours)
• Muscular causes – Hypertrophy of the scalene muscles Decrease of the tonus of the M. trapezius, M. levator scapulae, M.rhomboids
  Shortening of the scalene muscles, M. trapezius, M. levator scapulae, pectoral muscles
• Post-traumatic causes –  either due to isolated trauma or repeated trauma, account for up to 2/3 of cases in some series [Rx, Rx]. Post-traumatic TOS due to soft tissue injury raises medicolegal and often management problems. These forms are related to neck and shoulder trauma, particularly “whiplash” injuries, or sometimes upper limb trauma. Injuries to scalene muscles and their subsequent fibrosis are implicated in this process [Rx, Rx]. Diagnostic criteria of post-traumatic TOS are the pathogenic mechanism and the onset of symptoms within the first two years.

Others Causes of Thoracic Outlet Syndrome

• Trauma – (e.g., whiplash injuries) or repetitive strain is frequently implicated.Rarer acquired causes include tumors, hyperostosis, and osteomyelitis
• Anatomical defects – Inherited defects that are present at birth (congenital) may include an extra rib located above the first rib (cervical rib) or an abnormally tight fibrous band connecting your spine to your rib.
• Poor posture – Drooping your shoulders or holding your head in a forward position can cause compression in the thoracic outlet area.
• Trauma – A traumatic event, such as a car accident, can cause internal changes that then compress the nerves in the thoracic outlet. The onset of symptoms related to a traumatic accident often is delayed.
• Repetitive activity – Doing the same thing repeatedly can, over time, wear on your body’s tissue. You may notice symptoms of thoracic outlet syndrome if your job requires you to repeat a movement continuously, such as typing on a computer, working on an assembly line or lifting things above your head, as you would if you were stocking shelves.
• Pressure on your joints – Obesity can put an undue amount of stress on your joints, as can carrying around an oversized bag or backpack.

Symptoms of Thoracic Outlet Syndrome

There are a number of types of thoracic outlet syndrome, including

• Neurogenic (neurological) thoracic outlet syndrome – This form of thoracic outlet syndrome is characterized by compression of the brachial plexus. The brachial plexus is a network of nerves that come from your spinal cord and control muscle movements and sensation in your shoulder, arm and hand. In the majority of thoracic outlet syndrome cases, the symptoms are neurogenic.
• Vascular thoracic outlet syndrome – This type of thoracic outlet syndrome occurs when one or more of the veins (venous thoracic outlet syndrome) or arteries (arterial thoracic outlet syndrome) under the collarbone (clavicle) are compressed.
• Nonspecific-type thoracic outlet syndrome – This type is also called disputed thoracic outlet syndrome. Some doctors don’t believe it exists, while others say it’s a common disorder. People with nonspecific-type thoracic outlet syndrome have chronic pain in the area of the thoracic outlet that worsens with activity, but a specific cause of the pain can’t be determined.
• Muscle wasting in the fleshy base of your thumb (Gilliatt-Sumner hand)
• Numbness or tingling in your arm or fingers
• Pain or aches in your neck, shoulder or hand
• Weakening grip
• Discoloration of your hand (bluish color)
• Arm pain and swelling, possibly due to blood clots
• Blood clot in veins or arteries in the upper area of your body
• Lack of color (pallor) in one or more of your fingers or your entire hand
• Weak or no pulse in the affected arm
• Cold fingers, hands or arms
• Arm fatigue with activity
• Numbness or tingling in your fingers
• Weakness of arm or neck
• Throbbing lump near your collarbone

Diagnosis of Thoracic Outlet Syndrome

• The following pathologies are common differential diagnosis for TOS
• Carpal tunnel syndrome
• De Quervain’s tenosynovitis
• Lateral epicondylitis
• Medial epicondylitis
• Complex regional pain syndrome (CRPS I or II).
• Horner’s Syndrome
• Raynaud’s disease
• disease (especially discogenic)
• Brachial plexus trauma
• Systemic disorders: inflammatory disease, esophageal or cardiac disease
• Upper extremity deep venous thrombosis , Paget-Schroetter syndrome
• Rotator cuff pathology
• Glenohumeral joint instability
• Nerve root involvement
• Malignancies (local tumours)
• Chest pain, angina
• Vasculitis
• Thoracic 4 syndrome
• Sympathetic-mediated pain

Systematic causes of brachial plexus pain include 

• Pancoast’s Syndrome
• Radiation induced brachial plexopathy
• Parsonage Turner Syndrome
• carpal tunnel syndrome
• peripheral neuropathies (like ulnar nerve entrapment at the elbow, shoulder tendinitis and impingement syndrome)
• fibromyalgia of the shoulder and neck muscles
• cervical disc disease (like cervical spondylosis and herniated cervical disk)

Special Tests

• Elevated Arm Stress/ Roos test – The patient has arms at 90° abduction and the therapist puts downwards pressure on the scapula as the patient opens and closes the fingers. If the TOS symptoms are reproduced within 90 seconds, the test is positive.
• Adson’s – The patient is asked to rotate the head and elevate the chin toward the affected side. If the radial pulse on the side is absent or decreased then the test is positive, showing the vascular component of the neurovascular bundle is compressed by the scalene muscle or cervical rib.
• Wright’s  – The patient’s arm is hyper abducted. If there is a decrease or absence of a pulse on one side then the test is positive, showing the axillary artery is compressed by the pectoralis minor muscle or coracoid process due to stretching of the neurovascular bundle.
• Cyriax Release – The patient is seated or standing. The examiner stands behind the patient and grasps under the forearms, holding the elbows at 80 degrees of flexion with the forearms and wrists in neutral. The examiner leans the patient’s trunk posteriorly and passively elevated the shoulder girdle. This position is held for up to 3 minutes. The test is positive when paresthesia and/or numbness (release phenomenon) occurs, including a reproduction of symptoms.
• Supraclavicular Pressure – The patient is seated with the arms at the side. The examiner places his fingers on the upper trapezius and thumb on the anterior scalene muscle near the first rib. Then the examiner squeezes the fingers and thumb together for 30 seconds. If there is a reproduction of pain or paresthesia the test is positive, this addresses compromise to brachial plexus through scalene triangles.
• Costoclavicular Maneuver – This test may be used for both neurological and vascular compromise. The patient brings his shoulders posteriorly and hyperflexes his chin. A decrease in symptoms means that the test is positive and that the neurogenic component of the neurovascular bundle is compressed.
• Upper Limb Tension – These tests are designed to put stress on neurological structures of the upper limb. The shoulder, elbow, forearm, wrist, and fingers are kept in specific position to put stress on the particular nerve (nerve bias) and further modification in the position of each joint is done as “sensitizer”.
• Cervical Rotation Lateral Flexion – The test is performed with the patient in sitting. The cervical spine is passively and maximally rotated away from the side being tested. While maintaining this position, the spine is gently flexed as far as possible moving the ear toward the chest. A test is considered positive when the lateral flexion movement is blocked.

Others Test

• An X-ray of the thoracic outlet can reveal whether you have an extra rib. It may also rule out other conditions that could be causing your symptoms.
• An MRI uses powerful magnets and radio waves to create clear, detailed images of the thoracic outlet. The pictures can help determine the location and cause of the compression. They may also show certain structural abnormalities that could be causing your symptoms.
• Electromyography allows your doctor to see how well the muscles and nerves in the thoracic outlet are working. During this test, an electrode is inserted through your skin into various muscles. It evaluates the electrical activity of your muscles when at rest and when contracted.
• A nerve conduction study uses a low amount of electrical current to measure how quickly your nerves send impulses to various muscles throughout the body. It can determine whether you have nerve damage.

Treatment of Thoracic Outlet Syndrome

• Analgesics: Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants: A Drugs that block pain messages from your brain and boost the effects of eorphins .
• Medication – Common pain remedies such as aspirin, acetaminophen, ibuprofen and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenosis, such as muscle spasms and damaged nerves.
• Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your back or neck. Steroids make inflammation go down. However, because of side effects, they are used sparingly.
• Anesthetics – Used with precision, an injection of a “nerve block” can stop pain for a time.
• Muscle Relaxants – These medications provide relief from spinal muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentine) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bones health and healing fracture.

Others Treatment Approach

• Transaxillary approach  – The first rib forms the common denominator for all causes of nerve and artery compression in this region, so that its removal generally improves symptoms. Surgeon makes an incision in the chest to access the first rib, divide the muscles in front of the rib and remove a portion of the first rib to relieve compression, without disturbing the nerves or blood vessels.
• Supraclavicular approach – Has been advocated to perform first rib resection and scalenectomy, a safe and effective procedure, characterized by a shorter operative time and having a complication rate lower or comparable to that of transaxillary first rib resection.
  This approach repairs compressed blood vessels. The surgeon makes an incision just under the neck to expose the brachial plexus region. Then he looks for signs of trauma or muscles contributing to compression near the first rib. The first rib may be removed if necessary to relieve compression.
• Arterial TOS  – Decompression can include cervical and/or first rib removal and scalene muscle revision. The subclavian can then be inspected for degeneration, dilation, or an aneurysm. Saphenous vein graft or synthetic prosthesis can then be used if necessary Level of evidence 2B.
• Venous TOS – Thrombolytic therapy is the first line of treatment for these patients. Because of the risk of recurrence, many recommend removal of the first rib is necessary even when thrombolytic therapy completely opened the vein. The results of a study show that the infraclavicular approach is a safe and effective treatment for acute VTOS. They had no brachial plexus or phrenic nerve injuries.

Physical Therapy in Thoracic Outlet Syndrome

Conservative management should be the first strategy to treat TOS since this seems to be effective at decreasing symptoms, facilitating return to work and improving function, but yet a few studies have evaluated the optimal exercise program as well as the difference between a conservative management and no treatment.

Stage 1 – The aim of the initial stage is to decrease the patient’s symptoms. This may be achieved by patient education, in which TOS, bad postures, the prognosis and the importance of therapy compliance are explained. Furthermore some patients who sleep with the arms in an overhead, abducted position should get some information about their sleeping posture to avoid waking up at night.

• Cyriax release maneuver
• Elbows flexed to 90°
• Towels create a passive shoulder girdle elevation
• Supported spine and the head in neutral
• The position is held until peripheral symptoms are produced. The patient is encouraged to allow symptoms to occur as long as can be tolerated up to 30 minutes, observing for a symptom decrescendo as time passes.
• The patient’s breathing techniques need to be evaluated as the scalenes and other accessory muscles often compensate to elevate the rib cage during inspiration.
• Encouraging diaphragmatic breathing will lessen the workload on already overused or tight scalenes and can possibly reduce symptoms.

Stage 2 –  Once the patient has control over his/her symptoms, the patient can move to this stage of treatment. The goal of this stage is to directly address the tissues that create structural limitations of motion and compression. How this should be done is one of the most discussed topics of this pathology. Some examples of methods that are used in the literature are.

• Massage
•  Strengthening of the levator scapulae, sternocleidomastoid, and upper trapezius. This group of muscles open the thoracic outlet by raising the shoulder girdle and opening the costoclavicular space
• Stretching of the pectoralis, lower trapezius and scalene muscles

These muscles close the thoracic outlet

• Postural correction exercises
• Relaxation of shortened muscles  Level of evidence 1A
• exercises in a daily home exercise program
• Shoulder exercises to restore the range of motion and so provide more space for the neurovascular structures.

Exercise

• Lift your shoulders backwards and up, flex your upper thoracic spine and move the shoulders forward and down. Then straightened the back and repeat 5 to 10 times.ROM of the upper cervical spine

Exercise

• Lower your chin 5 to 10 times against your chest, while you are standing with the back of your head against a wall. The effectiveness of this exercise can be enlarged by pressing the head down by hands.
• Activation of the scalene muscles are the most important exercises. These exercises help to normalize the function of the thoracic aperture as well as all the malfunctions of the first rib.

Exercises

Anterior scalene

• Press your forehead 5 times against the palm of your hand for a duration of 5 seconds, without creating any movement.
  Middle scalene
• Press your head sidewards against your palm.
  Posterior scalene
• Press your head backwards against your palm.

 Stretching exercises

• Taping – some patients with severe symptoms respond to additional taping, adhesive bandages or braces that elevate or retract the shoulder girdle.
• Manipulative treatment to mobilize the first rib
• Repositioning/mobilization of the shoulder girdle and pelvis joints cervicothoracic, sternoclavicular, acromioclavicular, and costotransverse joints
• Glenohumeral mobilizations in end-range elevation with the elbow supported in extension 

Posterior Glenohumeral Glide with Arm Flexion

• The patient is supine. The mobilization hand contacts the proximal humerus avoiding coracoid process. The force is directed posterolaterally (direction of thumb).

Anterior Glenohumeral Glide with Arm Scaption

• The patient is prone. The mobilization hand contacts the proximal humerus avoiding the acromion process. The force is directed anteromedially.

Inferior Glenohumeral Glide

• The patient is prone. The stabilizing hand holds the proximal humerus the humerus distal to the lateral acromion process. The mobilization hand contacts the axillary border of the scapula. Mobilize the scapula in a craniomedial direction along the ribcage.

References

Dry mouth or xerostomia (zeer-o-STOE-me-uh), refers to a condition in which the salivary glands in your mouth don’t make enough saliva to keep your mouth wet. Dry mouth is often due to the side effect of certain medications or aging issues or as a result of radiation therapy for cancer. Less often, dry mouth may be caused by a condition that directly affects the salivary glands.

There are three pairs of relatively large, major salivary glands:

• Parotid glands. Located in the upper part of each cheek, close to the ear. The duct of each parotid gland empties onto the inside of the cheek, near the molars of the upper jaw.
• Submandibular glands. Under the jaw. They have ducts that empty behind the lower front teeth.
• Sublingual glands. Beneath the tongue. They have ducts that empty onto the floor of the mouth.

Causes of Dry Mouth

There are several causes of dry mouth, also called xerostomia. These include:

Medications

There are over 1,800 medications, both prescription and over-the-counter, that have a side effect of dry mouth. Some of the most commonly prescribed include:

• ADHD medications (methylphenidate and amphetamines)
• Narcotic pain relievers
• SSRI antidepressants
• Tricyclic antidepressants
• Bupropion 
• Sleep medications 
• Oxybutynin
• Antipsychotics
• Muscle relaxants
• Clonidine
• Everyday medicines, such as cold remedies and antihistamines

Age – While dry mouth tends to be more common in the elderly, it is not necessarily due to their age, but rather the fact that this population tends to take several medications. Half of all Americans aged 60 years or older take three or more prescription medications on a regular basis. Older people are also more likely to be affected by cancer and Sjögren’s syndrome, both of which cause dry mouth.

Sjögren’s Syndrome – Dry mouth is one of the more prominent symptoms of Sjögren’s syndrome. This disease affects the body’s immune system and attacks the tear and salivary glands. Females are more likely to suffer from this chronic condition as 90% of people with the disease are women.

Diabetes – One of the most common oral health problems of diabetics is dry mouth because diabetics have an increased risk of dehydration due to higher blood glucose levels. While thirst may be the first indicator people recognize, dry mouth and dry eyes are also a main symptom of dehydration. Learn how to treat dry mouth from diabetes.

Cancer and Treatment – Chemotherapy or radiation treatments can be damaging to the salivary glands of neck and head cancer patients specifically. Although some may regain partial salivary production after the first year of their treatment, many will continue to suffer from long-term dry mouth symptoms, especially if radiation was directed at their salivary glands.

Parkinson’s disease – Some people with Parkinson’s disease experience dry mouth because they swallow repeatedly, which uses up the saliva that is needed to be comfortable. Dry mouth may also be caused by some of the medications for Parkinson’s disease, particularly

Cancer treatment – Radiotherapy (radiation therapy) to the head and neck can damage the salivary glands, resulting in less saliva being produced. Chemotherapy can alter the nature of the saliva, as well as how much of it the body produces.

Injury or surgery – This can result in nerve damage to the head and neck area can result in dry mouth.

Nerve damage – An injury or surgery that causes nerve damage to your head and neck area can result in dry mouth.

Tobacco – Either chewing or smoking tobacco increases the risk of dry mouth symptoms.

Dehydration – This is caused by lack of sufficient fluids.

Exercising or playing in the heat – The salivary glands may become dry as bodily fluids are concentrated elsewhere in the body. Dry mouth symptoms are more likely if the exercise or playing continues for a long time.

Some health conditions, illnesses, and habits can cause dry mouth, such as:

• anxiety disorders
• depression
• HIV/AIDS
• Parkinson’s disease
• poorly controlled diabetes
• Sjögren’s syndrome
• sleeping with the mouth open
• snoring
• stroke and Alzheimer’s disease, although these are more likely to cause a perception of dry mouth even when the salivary glands are functioning appropriately

Symptoms of Dry Mouth

True hyposalivation may give the following signs and symptoms:

Dental caries (xerostomia related caries) – Without the anticarcinogenic actions of saliva, tooth decay is a common feature and may progress much more aggressively than it would otherwise (“rampant caries”). It may affect tooth surfaces that are normally spared, e.g., cervical caries and root surface caries. This is often seen in patients who have had radiotherapy involving the major salivary glands, termed radiation-induced caries. Therefore it’s important that any products used in managing dry mouth symptoms are sugar-free, as the presence of sugars in the mouth support the growth of oral bacteria, resulting in acid production and development of dental caries

• Acid erosion – Saliva acts as a buffer and helps to prevent demineralization of teeth.
• Oral candidiasis – A loss of the antimicrobial actions of saliva may also lead to opportunistic infection with Candida species.
• Ascending (suppurative) sialadenitis – an infection of the major salivary glands (usually the parotid gland) that may be recurrent. It is associated with hyposalivation, as bacteria are able to enter the ductal system against the diminished flow of saliva. There may be swollen salivary glands even without acute infection, possibly caused by autoimmune involvement.
• Dysgeusia – altered taste sensation (e.g., a metallic taste)and dysosmia, altered sense of smell.
• Intraoral halitosis – possibly due to increased activity of halitogenic biofilm on the posterior dorsal tongue (although dysgeusia may cause a complaint of nongenuine halitosis in the absence of hyposalivation).
• Oral dysesthesia – a burning or tingling sensation in the mouth.
• Saliva that appears thick or ropey.
• Mucosa that appears dry.
• A lack of saliva pooling in the floor of the mouth during the examination.
• Dysphagia – difficulty swallowing and chewing, especially when eating dry foods. Food may stick to the tissues during eating.
• The tongue may stick to the palate, causing a clicking noise during the speech, or the lips may stick together.
• Gloves or a dental mirror may stick to the tissues.
• Fissured tongue with atrophy of the filiform papillae and a lobulated, erythematous appearance of the tongue.
• Saliva cannot be “milked” (expressed) from the parotid duct.
• Difficulty wearing dentures, e.g., when swallowing or speaking. There may be generalized mucosal soreness and ulceration of the areas covered by the denture.
• fungal infections in the mouth, such as thrush
• glossodynia, or a painful tongue
• increased need to drink water, especially at night
• inflammation of the tongue, tongue ulcers
• lipstick sticking to teeth
• more frequent gum disease
• more tooth decay and plaque
• problems speaking
• problems swallowing and chewing – especially dry and crumbly foods, such as crackers or cereals
• problems wearing dentures – problems with denture retention, denture sores, and the tongue sticking to the palate
• sialadenitis, a salivary gland infection
• a sore throat
• sticky saliva
• stringy saliva
• Mouth soreness and oral mucositis.
• Lipstick or food may stick to the teeth.
• A need to sip drinks frequently while talking or eating.
• Dry, sore, and cracked lips and angles of the mouth.
• Thirst.

Diagnosis of Dry Mouth

Tests vary depending on the condition thought to be causing the problem.

• Images of the glands can be seen using ultrasound, MRI scan, and CT scans of the glands.
• The ducts of the mouth can be investigated using an x-ray called a sialogram.
• A salivary gland biopsy can be used to diagnose problems with the salivary glands.
• Salivary flow rate — In this test, the amount of saliva produced during a specified amount of time may be measured. The test is non-invasive and painless.
• Scintigraphy — Performed in the hospital, this test measures the rate at which a small amount of injected radioactive material is taken up from the blood by the salivary glands and secreted into the mouth. It is another method to measure salivary flow rate.
• Biopsy of minor salivary glands — A small, shallow incision is made inside the lower lip to remove at least four of minor salivary glands. A pathologist then examines them for changes characteristic of the salivary component of Sjögren’s syndrome.
• Sialometry –This is a simple procedure that measures the flow rate of saliva. Collection devices are placed over duct orifices of the saliva glands, and saliva production is stimulated with citric acid.
• Saliography – This is a radiographic examination of the salivary glands and ducts. It may be useful in identifying salivary gland stones and masses.
• Biopsy – A small sample of salivary gland tissue is taken. Often used in the diagnosis of Sjögren’s syndrome. If malignancy (cancer) is suspected, the doctor may also order a biopsy.

Treatment of dry mouth

• Change the medication producing the dry mouth
• Sipping water or melting ice in the mouth
• Prescription dentifrices such as President and Clinpro 5000
• OTC and Internet dentifrices containing higher amounts of xylitol (10% to 36%) to control acidophilic bacteria (Tom’s of Maine, Spry by Xlear)
• OTC dentifrices containing triclosan or sodium bicarbonate (both have antimicrobial properties)
• Refrain from using dentifrices containing the drying agent SLS
• OTC fluoride or xylitol mouth rinses (ACT Dry Mouth Mouthwash)
• Regular use of xylitol-containing (first listed ingredient) products that mechanically stimulate salivary flow and discourage S. mutans (TheraGum by 3M ESPE and X-Pur mints and gum by Oral Science, Canada)
• OTC saliva substitutes that stimulate, moisten, and lubricate oral tissues, palliative products that contain carboxymethylcellulose (CMC), calcium and phosphorus, fluoride and other typical salivary ions (Biotene products by GlaxoSmithKline)
• Gels that neutralize oral pH (Dry Mouth Gel, GC America) and lozenges (SalivaSure) with citric acid that chemically stimulate salivary flow (available on the Internet, several manufacturers and distributors)
• Adhesive tablets applied to the palate (OraMoist by Quantum Health and XyliMelts by Oral Health) contain xylitol, a lubricant, oral enzymes, buffering compounds, and salivary secretion inducers
• Application of vitamin E-containing ointment to dry lips
• OTC (Oasis and Salivart Spray) and prescription artificial saliva (Neutra-sal) products that contain buffering and flavoring agents but no digestive enzymes or proteins
• Customized night trays with remineralizing agents (several products available)
• Prescription sialagogue medications such as pilocarpine (Salagen), cevimeline HCl (Evoxac), anethole trithione (Sialor) and bethanechol (Urecholine). These drugs enhance secretion for a few hours. Patients should increase fluid intake during use. NOTE: The ADA does not currently recommend the use of salivary-stimulating drugs due to a lack of quality evidence-based research on the efficacy of drugs that increase the flow rate of saliva.
• Pilocarpine- Pilocarpine is a cholinergic parasympathomimetic agent with predominantly muscarinic M3 action that causes stimulation of residual-functioning exocrine glands. The tablets are indicated for the treatment of symptoms of dry mouth from salivary gland hypofunction caused by Sjögren’s syndrome or by radiotherapy for cancer of the head and neck. The time to reach peak concentrations following oral administration is approximately 1.25 hours.
• Pilocarpine- is contraindicated in patients with uncontrolled asthma, narrow-angle glaucoma or iritis. It is pregnancy category C. The most common side effects are increased sweating and gastrointestinal intolerance. Hypotension, rhinitis, diarrhea and visual disturbances can also occur. The recommended initial dose is one 5 mg tablet taken TID or QID;
• Cevimeline- Cevimeline is a cholinergic agonist with a high affinity for the muscarinic M3 receptors located on lacrimal and salivary gland epithelium, leading to an increase in exocrine gland secretions including saliva and sweat. It is indicated for the treatment of symptoms of dry mouth in patients with Sjögren’s syndrome. It is rapidly absorbed from the gastrointestinal tract, reaching peak concentrations in approximately 90 minutes without food
• Xylitol -has beneficial oral effects: bacteriostatic and moisturizer, while it boosts the anticaries and remineralizing effects of Sodium fluoride. Betaine, Allantoin, and Aloe vera, thanks to their anti-irritant, regenerative and healing effects on tissues,

Additional Rx

The management of salivary gland dysfunction may involve the use of saliva substitutes and/or saliva stimulants:

Saliva substitutes – These are viscous products which are applied to the oral mucosa, which can be found in the form of sprays, gels, oils, mouthwashes, mouth rinses, pastilles or viscous liquids. This includes SalivaMAX, water, artificial salivas (mucin-based, carboxymethylcellulose-based), and other substances (milk, vegetable oil)

• Mucin Spray: 4 Trials have been completed on the effects of Mucin Spray on Xerostomia, overall there is no strong evidence showing that Mucin Spray is more effective than a placebo in reducing the symptoms of dry mouth.
• Mucin Lozenge: Only 1 trial (Gravenmade 1993) has been completed regarding the effectiveness of Mucin Lozenges. Whilst it was assessed as being at high risk of bias, it showed that Mucin Lozenges were ineffective when compared to a placebo.
• Mucoadhesive Disk: These disks are stuck to the palate and they contain lubricating agents, flavouring agents and some antimicrobial agents. One trial (Kerr 2010) assessed their effectiveness against a placebo disk. Strangely, patients from both groups (placebo and the real disk) reported an increase in subjective oral moistness. No adverse effects were reported. More research is needed in this area before conclusions are drawn.

• Biotene Oral Balance Gel & toothpaste: One trial has been completed (Epstein 1999) regarding the effectiveness of Biotene Oral Balance gel & toothpaste. The results showed that Biotene products were “more effective than control and reduced dry mouth on waking”.

Saliva stimulants – organic acids (ascorbic acid, malic acid), chewing gum, parasympathomimetic drugs (choline esters, e.g. pilocarpine hydrochloride, cholinesterase inhibitors), and other substances (sugar-free mints, nicotinamide). Medications which stimulate saliva production traditionally have been administered through oral tablets, which the patient goes on to swallow, although some saliva stimulants can also be found in the form of toothpaste. Lozenges, which are retained in the mouth and then swallowed are becoming more and more popular. Lozenges are soft and gentle on the mouth and there is a belief that prolonged contact with the oral mucosa mechanically stimulates saliva production. Pilocarpine: A study by Taweechaisupapong in 2006 showed no ‘statistical significant improvement in oral dryness and saliva production compared to placebo’ when administering pilocarpine lozenges.Physostigmine Gel: A study by Knosravini in 2009 showed a reduction in the oral dryness and a 5 times increase in saliva following physostigmine treatment.

• Chewing gum increases saliva production but there is no strong evidence that it improves dry mouth symptoms.
• The Cochrane oral health group concluded ‘there is insufficient evidence to determine whether pilocarpine or physostigmine’ are effective treatments for Xerostomia. More research is needed.
• Detrol chewing gum (xylitol) –  A study by Risheim in 1993 showed that when subjects had 2 sticks of gum up to 5 x daily, the gum gave subjective dry mouth symptom relief in approximately 1/3 of participants but no change in SWS (stimulated the whole saliva).
• Profilin lozenge (xylitol/sorbitol) – A study by Risheim in 1993 showed that when subjects had 1 lozenge 4 to 8 x daily, profilin lozenges gave subjective dry mouth symptom relief in approximately 1/3 of participants but no change in SWS (stimulated whole saliva)

How can I manage my symptoms of dry mouth

• Drink liquids as directed. You may need to drink more water than usual. It may help to sip small amounts throughout the day. This will help keep your mouth moist. Do not drink caffeine or alcohol. Do not drink acidic juices such as tomato, orange, or grapefruit.
• Eat soft, moist foods. Choose foods that are cool or room temperature. Moisten dry foods with milk, broth, or other sauces. Healthy foods include fruits, vegetables, whole-grain bread, low-fat dairy products, beans, lean meats, and fish.
• Brush at least twice each day. This will help prevent tooth decay and cavities. You may need to brush after each meal as well. Use a soft toothbrush and fluoride toothpaste. Floss gently once each day. Use over-the-counter mouthrinses that help increase saliva. Do not use mouth rinses that have alcohol.
• Chew sugarless gum or suck on sugar-free candy. This will help increase saliva production.
• Use a cool mist humidifier. A humidifier will increase air moisture in your home. This may help moisten your mouth, especially at night.
• Rinse your mouth 4 times each day. Rinse after every meal. Use a mixture of salt and baking soda. Mix ½ teaspoon of salt and ½ teaspoon of baking soda in 1 cup of warm water.
• Do not smoke. Tobacco products can dry out your mouth. Do not use e-cigarettes or smokeless tobacco in place of cigarettes or to help you quit. They still contain nicotine. Ask your healthcare provider for information if you currently smoke and need help to quit.

Home Remedies for dry mouth include

Cayenne Pepper

When our taste buds and nerve endings experience an extreme stimulant, the body’s natural response is to produce saliva. For example, when we eat something spicy, we begin to salivate in order to soothe the burning sensation, so if you’re suffering from dry mouth, take a bit of cayenne powder and rub it on your tongue or gums.

Lemon

The citric acid found in lemons and lemon juice can quickly stimulate the production of saliva, and also protect your mouth from infections that can contribute to bad breath and other oral issues. You can rub a slice of lemon on your tongue, mix lemon juice with honey, or simply suck on a lemon slice to eliminate your dry mouth.

Aloe Vera

This is one of the oldest and most trusted remedies for dry mouth. Aloe vera juice is rich in antioxidants, nutrients, and naturally hydrating substances, and can also stimulate the production of saliva in the mouth. Furthermore, aloe vera can enhance the function of the tastebuds and protect you from oral infections.

Extra Water

Although dehydration isn’t the sole cause of dry mouth, it is certainly to blame some of the time. If you increase your daily intake of water, you’re much less likely to suffer from dry mouth, as it will increase the amount of saliva that your body produces, and also lubricates the throat, gums, and lips, preventing some of the more uncomfortable side effects of xerostomia.

Grapeseed Oil

There are a number of natural moisturizing properties of grapeseed oil that makes it very good at preventing or eliminating dry mouth symptoms. Simply rub a small amount of grapeseed oil on your gums and on your tongue, and it should keep your mouth hydrated and moisturized for hours!

Get a Humidifier

If you regularly wake up in the middle of the night suffering from dry mouth, it may be because the environment of your bedroom is too dry. Getting a humidifier can be a simple and effective way to handle dry mouth and ensure that you have restful, undisturbed sleep.

Different Medications

If you find yourself suffering from xerostomia and are also taking a new medication, try speaking to your doctor about alternative prescriptions that don’t have dry mouth as such a consistent symptom, as those medications are very commonly the root cause of your suffering.

Develop a Sweet Tooth

Anecdotal evidence suggests that sucking on hard candy or chewing on sugar-free gum can quickly stimulate the production of saliva, so if you feel a bout of cotton mouth coming on, simply pop a piece of candy and the problem should clear itself up in no time!

Change Your Breathing Pattern

One of the quickest ways to dry out your mouth is to continually breathe through your mouth. If you are constantly bringing dry air into your mouth and throat, that air will rob you of hydration, thus drying out your mouth. If you can consciously try to breathe through your nose and out through your mouth, you are far less likely to experience dry mouth.

Quit Smoking

All tobacco products dry out the mouth, so if you’re a regular smoker, or chew tobacco, don’t be surprised if you suffer from dry mouth. The best way to eliminate the problem, obviously, is to cease all use of tobacco products, not only for the sake of your xerostomia, but also the many other health risks that smoking and tobacco use incurs.

Reduce Caffeine Intake

Studies have shown that caffeine can dehydrate the body and also dry out the mouth, so eliminating coffee, or at least cutting back to one cup a day, should keep your mouth properly salivated all day.

Limit Alcohol Consumption

There is a good reason why you feel so thirsty and weak after a long night of drinking. Alcohol dehydrates the body faster than almost any other substance, so if you regularly suffer from xerostomia, your alcohol intake is certainly not helping.

Homeopathic Remedies

• Arsenic Alb – Accompanied with a thirst for small quantities of water at short intervals.
• Bryonia – with a thirst for large quantities of water, dryness from mouth to rectum. 
• Nux mosch – Great dryness, tongue so dry that adheres to the roof of the mouth.
  Saliva seems like cotton, throat dry,stiffened.
  no thirst.
• Lachesis – Dryness of mouth.
  the patient is unable to protrude his tongue
• Nux vomica
  Breath offensive after meals in the morning.
• Pulsatilla
  breath offensive in the evening.
• Auram met
  breath offensive in girls at puberty.
• Arum Trip
  Putrid odor from the mouth.

References