---
title: "Dry mouth after radiotherapy"
url: "https://acuiq.com/wiki/evidence/xerostomia"
updated: 2026-10-11
last_verified: 2026-10-11
license: CC-BY-4.0
license_url: "https://creativecommons.org/licenses/by/4.0/"
section: "evidence"
basis: "Modern research"
audience: "Anyone"
published: "2026-10-11"
reading_minutes: 11
sources: 16
---

# Dry mouth after radiotherapy

_What the Cochrane review, six later reviews, five trials and the ISOO/MASCC/ASCO guideline say about acupuncture to prevent or treat dry mouth after radiotherapy for head and neck cancer._

Radiotherapy to the head and neck predictably damages the salivary glands, and the [2017 Cochrane review of drugs to prevent it](https://doi.org/10.1002/14651858.CD012744) uses two terms for the result: xerostomia, the sensation of a dry mouth, and salivary gland hypofunction, a measurable fall in the saliva the glands produce. Acupuncture trials ask two separate questions about it: whether needling during radiotherapy prevents the dryness, and whether needling months or years afterwards eases it. Two multicentre trials with a sham arm, [Garcia 2019](https://doi.org/10.1001/jamanetworkopen.2019.16910) and [Cohen 2024](https://doi.org/10.1001/jamanetworkopen.2024.10421), one for each question and with 339 and 258 people, compared true acupuncture with sham acupuncture, a procedure made to resemble it, and with standard care. Both found true acupuncture ahead of standard care; against sham, the difference was smaller and depended on the site or the statistical adjustment. Cochrane’s review covering acupuncture dates from 2013 and predates both.

## What the trials measure

Most of the trials below score symptoms with the Xerostomia Questionnaire (XQ), on which a higher score means a drier mouth; [Garcia 2019](https://doi.org/10.1001/jamanetworkopen.2019.16910) counted a score above 30 as clinically significant xerostomia. They also measure saliva directly, as unstimulated flow, collected at rest, and stimulated flow, collected while the person chews or tastes something. The two kinds of outcome can disagree. The authors of the [2013 Cochrane review](https://doi.org/10.1002/14651858.CD009603.pub3) noted that dry mouth can be troublesome even when saliva production rises, and called it a reporting bias that only two of the acupuncture trials they found reported symptoms at all.

## The Cochrane reviews

The [Cochrane review of non-pharmacological interventions for dry mouth](https://doi.org/10.1002/14651858.CD009603.pub3) by Susan Furness and colleagues, published in September 2013 with searches to April 2013, is the most recent Cochrane review that includes acupuncture. Five small trials, 153 people with dry mouth after radiotherapy, compared acupuncture with placebo; four were at high risk of bias. Two of them, 70 people, reported dry mouth in a form that could be pooled, and found no difference between acupuncture and placebo (standardised mean difference −0.34, 95% CI −0.81 to 0.14; low-quality evidence). Unstimulated saliva rose by 0.02 ml a minute at the end of treatment (3 trials, 71 people) and stimulated saliva by 0.19 ml a minute (3 trials, 71 people), both low-quality evidence, and both differences were still present at 12 months in two trials of 54 people. Acupuncture brought more adverse effects than placebo, tiny bruises and tiredness, which were mild and short-lived. The authors suggested the null result on symptoms could reflect too few participants, or some benefit from the placebo procedure itself.

The [2017 Cochrane review by Philip Riley and colleagues](https://doi.org/10.1002/14651858.CD012744) on preventing dry mouth during radiotherapy covered pharmacological interventions only, 39 trials and 3,520 people, so it has no acupuncture comparison. A PubMed search of the Cochrane Database of Systematic Reviews on 11 October 2026 found no later Cochrane review of interventions for dry mouth.

## Later reviews

None of the reviews below is a Cochrane review. Some pool trials against sham with trials against standard care, oral care education or pilocarpine, a drug that stimulates saliva; where a review kept them apart, the table says so.

| Review | Trials and people | Comparison | Finding | Certainty |
| --- | --- | --- | --- | --- |
| [Assy 2018](https://doi.org/10.1186/s12906-018-2124-x) | 10 trials; dry mouth from radiotherapy and other causes | Sham (5); oral hygiene or usual care (4); oral care sessions (1) | Insufficient evidence to conclude either way | Low for all main outcomes |
| [Ni 2020](https://doi.org/10.1177/1534735420980825), searched to December 2019 | 8 trials, 725 people; 3 pooled | Sham, kept apart from no acupuncture | Against sham, XQ 3.05 points lower (95% CI −5.58 to −0.52) with no difference in saliva flow; against no acupuncture, better reported symptoms | GRADE low for every outcome; all trials at high risk of bias |
| [Dörfler 2023](https://doi.org/10.1002/hed.27297), umbrella review, searched February 2022 | 8 systematic reviews covering 12 controlled studies | As in the reviews | Most reviews found no difference from sham on objective measures and some favourable effects on symptoms | Reviews appraised with AMSTAR-2 |
| [Gu 2025](https://doi.org/10.1089/jicm.2023.0781), searched to July 2024 | 8 trials, 1,273 people; 6 pooled | Standard care and sham, kept apart | Against standard care, SMD −0.20 (−0.38 to −0.02); against sham, SMD −0.06 (−0.29 to 0.16); no difference in saliva flow | Not stated in the abstract |
| [Tsai 2025](https://doi.org/10.7150/ijms.110366), searched to September 2024 | 11 trials, 1,271 people | Acupuncture and nerve stimulation against sham, standard care or pilocarpine, pooled together | Moderate rise in saliva flow; better symptom and quality-of-life scores; heterogeneity I² 55% to 77% | Not graded |
| [Cheng 2025](https://doi.org/10.1002/hed.70100), network meta-analysis, searched to October 2024 | 46 trials, 3,802 people, 10 kinds of non-drug intervention | Against each other and against passive controls | Acupuncture better than passive controls on every outcome, ranked below combined treatments and herbal medicine | Not stated in the abstract |

A standardised mean difference (SMD) expresses the gap between groups in units of the spread of scores. Heterogeneity, given as I², measures how much the trials disagree beyond what chance explains. Tsai and colleagues, in Taiwan, also reported that Egger’s test suggested publication bias (p = 0.078). Dörfler and colleagues, in Germany, concluded that no clinically meaningful effect of acupuncture on xerostomia had been proven so far, while the favourable findings on symptoms called for further study.

## Trials

- **Prevention, against standard care, 2012.** A [trial](https://doi.org/10.1002/cncr.26550) by Zhiqiang Meng and colleagues at Fudan University Shanghai Cancer Center randomised 86 people with nasopharyngeal carcinoma to acupuncture three times a week on radiotherapy days, or to standard care. XQ scores were lower with acupuncture from week 3 of radiotherapy through 6 months afterwards.
- **Treatment, against oral care education, 2013.** The [ARIX trial](https://doi.org/10.1093/annonc/mds515), led by Richard Simcock in seven UK cancer centres, recruited 145 people with dry mouth more than 18 months after radiotherapy and gave them, in a crossover design, two group sessions of oral care education and eight of group acupuncture. Acupuncture was followed by fewer reports of severe dry mouth (odds ratio 2.01, P = 0.031), sticky saliva, and waking at night to drink. Stimulated and unstimulated saliva did not change.
- **Treatment, nerve stimulation against pilocarpine, 2015.** The [RTOG 0537 trial](https://doi.org/10.1016/j.ijrobp.2015.01.050), reported by Raimond Wong and colleagues, randomised 148 people to 24 sessions over 12 weeks of acupuncture-like transcutaneous electrical nerve stimulation (ALTENS), which applies current through skin pads at acupuncture points, or to pilocarpine. Only 96 could be evaluated at 9 months, and the change in symptom burden did not differ between the groups. Adverse events occurred in 20.8% with ALTENS and 61.6% with pilocarpine.
- **Prevention, against sham and standard care, 2019.** The [trial](https://doi.org/10.1001/jamanetworkopen.2019.16910) by M. Kay Garcia, Lorenzo Cohen and colleagues ran at MD Anderson Cancer Center in Houston and Fudan University Shanghai Cancer Center, enrolling people with oropharyngeal or nasopharyngeal cancer between 2011 and 2015. Of 399 randomised, 339 were analysed. True or sham acupuncture was given three times a week through a 6 to 7 week course of radiotherapy. The sham combined a real needle at a real point not indicated for dry mouth, real needles at sham points and non-penetrating placebo needles at sham points. One year after radiotherapy, adjusted XQ scores were 26.6 with true acupuncture, 31.3 with sham and 34.8 with standard care: true acupuncture differed from standard care (P = .001) but not significantly from sham (P = .06). Clinically significant xerostomia affected 34.6%, 47.8% and 55.1%. The two sites disagreed about the sham. In Shanghai, true acupuncture scored 8.2 points below sham (P = .001) and sham did not differ from standard care; in Houston, sham scored 10.5 points below standard care (P = .002) and true acupuncture did not differ from sham. One adverse event was related to acupuncture, pain at one needle site in the ear.
- **Treatment, against sham and standard oral hygiene, 2024.** The [US multicentre trial](https://doi.org/10.1001/jamanetworkopen.2024.10421) by Cohen, Suzanne Danhauer, Garcia and colleagues recruited through the Wake Forest National Cancer Institute Community Oncology Research Program Research Base: 258 people at 33 community sites in 13 states, with moderate to severe dry mouth 12 months or more after radiotherapy and a mean of 4.2 years since diagnosis. All kept to standard oral hygiene, and they were randomised in equal thirds to oral hygiene alone or to true or sham acupuncture twice a week for 4 weeks, with 4 more weeks for those who had a minor response. True acupuncture used three points on each ear, [`CV24`](/points/CV24) (Chengjiang) on the chin, [`LU07`](/points/LU07) (Lieque) on each forearm, a point on each hand and [`KD06`](/points/KD06) (Zhaohai) on each leg. The sham used non-penetrating needles at inactive body sites and real needles at three points on the rim of each ear. At week 4, the primary time point, XQ scores were 50.6 with true acupuncture, 55.0 with sham and 57.3 with oral hygiene alone. True acupuncture differed from oral hygiene by 6.67 points (95% CI −11.08 to −2.27); its 4.41-point difference from sham (95% CI −8.62 to −0.19, P = .04) did not hold after adjustment for multiple comparisons, and sham did not differ from oral hygiene. By week 26 only the sham group still scored lower than oral hygiene. No serious adverse events occurred; in the true acupuncture group one person had bruising, one a headache and one high blood pressure.

The 2012, 2019 and 2024 trials share investigators: Garcia, Cohen, the radiation oncologist David Rosenthal and the dental oncologist Mark Chambers of MD Anderson are authors of all three. [Sham acupuncture](/wiki/research/sham-acupuncture) sets out what penetrating and non-penetrating shams can and cannot rule out.

## What guidelines say

The [ISOO/MASCC/ASCO guideline](https://doi.org/10.1200/JCO.21.01208) on salivary gland hypofunction and xerostomia after cancer treatment, published in July 2021 by Vanessa Mercadante and colleagues for the International Society of Oral Oncology, the Multinational Association of Supportive Care in Cancer and the American Society of Clinical Oncology, searched trials published to June 2020. It says acupuncture may be offered during radiotherapy for head and neck cancer to reduce the risk of xerostomia (evidence quality intermediate, strength of recommendation moderate), resting on two trials of 109 people and the 339-person Garcia trial, and adds that there is no evidence it increases salivary flow. It says acupuncture may be offered after radiotherapy (evidence quality low, recommendation weak), noting that the evidence is one study, ARIX; ALTENS and other transcutaneous electrostimulation get the same low, weak rating. The 2024 trial postdates its search, and AcuiQ found no update to it in Europe PMC by October 2026.

A [2024 MASCC/ISOO clinical practice statement](https://doi.org/10.1007/s00520-024-08688-9) by Catherine Hong and colleagues, a short practical manual rather than a graded guideline, lists acupuncture among interventions tested in a few randomised trials and calls a recommendation for routine clinical use premature, because the evidence conflicts and treatment protocols vary. The [2022 Society for Integrative Oncology–ASCO guideline](https://doi.org/10.1200/JCO.22.01357) on integrative medicine covers pain and does not address dry mouth. [Nausea from chemotherapy](/wiki/evidence/nausea-from-chemotherapy) and [Cancer-related fatigue](/wiki/evidence/cancer-related-fatigue) cover other cancer treatment effects.

## What the reviews could not settle

Whether true acupuncture differs from sham is unresolved. The pooled comparisons disagree: [Ni 2020](https://doi.org/10.1177/1534735420980825) found a difference on symptoms, [Gu 2025](https://doi.org/10.1089/jicm.2023.0781) did not, and Cochrane’s 2013 pooling of 70 people found none. In Garcia 2019 the sham behaved differently in Houston and Shanghai, and in Cohen 2024 the difference at week 4 did not survive adjustment for multiple comparisons. Both shams placed some real needles, and the 2024 authors wrote that their sham cannot be considered a true placebo. Symptoms and saliva also diverge: several trials and reviews found change in one without the other. Most trials measured symptoms for weeks or months; in the 2024 trial the difference from oral hygiene had gone by week 26, and its authors noted that no maintenance treatment was given. The guideline that recommends acupuncture predates the 2024 trial, and Cochrane has not revisited the question since 2013. [Dry eye disease](/wiki/evidence/dry-eye) covers a condition with the same split between symptoms and measured secretion.

AcuiQ’s [xerostomia](/symptoms/xerostomia) page lists the protocols individual studies prescribed, each with its citation.

### Sources

1. Furness S, Bryan G, McMillan R, Birchenough S, Worthington HV, Interventions for the management of dry mouth: non-pharmacological interventions, Cochrane Database of Systematic Reviews 2013 — https://doi.org/10.1002/14651858.CD009603.pub3
2. Riley P, Glenny AM, Hua F, Worthington HV, Pharmacological interventions for preventing dry mouth and salivary gland dysfunction following radiotherapy, Cochrane Database of Systematic Reviews 2017 — https://doi.org/10.1002/14651858.CD012744
3. Assy Z, Brand HS, A systematic review of the effects of acupuncture on xerostomia and hyposalivation, BMC Complementary and Alternative Medicine 2018 — https://doi.org/10.1186/s12906-018-2124-x
4. Ni X, Tian T, Chen D, et al., Acupuncture for radiation-induced xerostomia in cancer patients: a systematic review and meta-analysis, Integrative Cancer Therapies 2020 — https://doi.org/10.1177/1534735420980825
5. Dörfler J, Freuding M, Zaiser C, et al., Umbrella review: summary of findings for acupuncture as treatment for radiation-induced xerostomia, Head & Neck 2023 — https://doi.org/10.1002/hed.27297
6. Gu W, Dong H, Yuan Y, et al., Is acupuncture an effective treatment for radiation-induced xerostomia of patients with head and neck cancer? A systematic review and meta-analysis, Journal of Integrative and Complementary Medicine 2025 — https://doi.org/10.1089/jicm.2023.0781
7. Tsai RY, Lin SY, Chen CC, Hsiao Y, Efficacy of acupuncture in managing radiation-induced xerostomia: an updated meta-analysis, International Journal of Medical Sciences 2025 — https://doi.org/10.7150/ijms.110366
8. Cheng X, Wang L, Ho MH, et al., Non-pharmacological interventions for improving xerostomia among patients with head and neck cancer: a systematic review and network meta-analysis, Head & Neck 2025 — https://doi.org/10.1002/hed.70100
9. Meng Z, Garcia MK, Hu C, et al., Randomized controlled trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma, Cancer 2012 — https://doi.org/10.1002/cncr.26550
10. Simcock R, Fallowfield L, Monson K, et al., ARIX: a randomised trial of acupuncture v oral care sessions in patients with chronic xerostomia following treatment of head and neck cancer, Annals of Oncology 2013 — https://doi.org/10.1093/annonc/mds515
11. Wong RK, Deshmukh S, Wyatt G, et al., Acupuncture-like transcutaneous electrical nerve stimulation versus pilocarpine in treating radiation-induced xerostomia: results of RTOG 0537 phase 3 study, International Journal of Radiation Oncology Biology Physics 2015 — https://doi.org/10.1016/j.ijrobp.2015.01.050
12. Garcia MK, Meng Z, Rosenthal DI, et al., Effect of true and sham acupuncture on radiation-induced xerostomia among patients with head and neck cancer: a randomized clinical trial, JAMA Network Open 2019 — https://doi.org/10.1001/jamanetworkopen.2019.16910
13. Cohen L, Danhauer SC, Garcia MK, et al., Acupuncture for chronic radiation-induced xerostomia in head and neck cancer: a multicenter randomized clinical trial, JAMA Network Open 2024 — https://doi.org/10.1001/jamanetworkopen.2024.10421
14. Mercadante V, Jensen SB, Smith DK, et al., Salivary gland hypofunction and/or xerostomia induced by nonsurgical cancer therapies: ISOO/MASCC/ASCO guideline, Journal of Clinical Oncology 2021 — https://doi.org/10.1200/JCO.21.01208
15. Hong C, Jensen SB, Vissink A, et al., MASCC/ISOO clinical practice statement: management of salivary gland hypofunction and xerostomia in cancer patients, Supportive Care in Cancer 2024 — https://doi.org/10.1007/s00520-024-08688-9
16. Mao JJ, Ismaila N, Bao T, et al., Integrative medicine for pain management in oncology: Society for Integrative Oncology–ASCO guideline, Journal of Clinical Oncology 2022 — https://doi.org/10.1200/JCO.22.01357