What are the treatment options for dry mouth (xerostomia)?

From the Guidelines

Dry mouth (xerostomia) can be effectively managed with a combination of lifestyle modifications, non-pharmacological interventions, and medical treatments, prioritizing the most recent and highest quality evidence from the 2024 NCCN guidelines. According to the latest guidelines 1, treatment options for dry mouth include:

• Dietary modifications
• Topical measures such as saliva substitutes and mouth rinses
• Systemic sialagogues like cevimeline or pilocarpine for moderate or severe symptoms
• Prednisone for patients with moderate or severe symptoms
• Referral to rheumatology and dentistry for comprehensive care. The NCCN panel recommends holding immunotherapy for patients with moderate or severe dry mouth and considering rechallenge after symptoms improve. Additionally, patients can benefit from:
• Increasing water intake throughout the day
• Avoiding caffeine, alcohol, and tobacco
• Using sugar-free gum or lozenges to stimulate saliva production
• Maintaining good oral hygiene with regular dental checkups, fluoride treatments, and alcohol-free mouthwash. It is essential to note that severe sicca syndrome, if left untreated, can result in dental caries and eventually the loss of teeth, highlighting the importance of prompt and effective management 1.

From the FDA Drug Label

Pilocarpine hydrochloride tablets are indicated for 1) the treatment of symptoms of dry mouth from salivary gland hypofunction caused by radiotherapy for cancer of the head and neck; and 2) the treatment of symptoms of dry mouth in patients with Sjogren’s Syndrome. A 12-week, randomized, double-blind, parallel-group, placebo-controlled study was conducted in 256 patients (14 men, 242 women) whose mean age was 57 years with a range of 24 to 85 years. After 6 weeks of treatment, statistically significant global improvement of dry mouth was observed compared to placebo Patients’ assessments of specific dry mouth symptoms such as severity of dry mouth, mouth discomfort, ability to speak without water, ability to sleep without drinking water, ability to swallow food without drinking, and a decreased use of saliva substitutes were found to be consistent with the significant global improvement described

The treatment options for dry mouth (xerostomia) include pilocarpine hydrochloride tablets. The recommended dosage is 5 mg four times a day (20 mg/day) for 6 weeks, which can be increased to 7.5 mg q.i.d..

• Key benefits of pilocarpine hydrochloride tablets include:
  • Global improvement of dry mouth
  • Improvement in specific dry mouth symptoms such as severity of dry mouth, mouth discomfort, and ability to speak without water
  • Decreased use of saliva substitutes 2 2

From the Research

Treatment Options for Dry Mouth (Xerostomia)

• The primary treatment to reduce xerostomia is oral pilocarpine, which has been shown to have some efficacy in the treatment of xerostomia from radiation therapy, graft-versus-host disease, and Sjögren's syndrome 3.
• Pilocarpine mouthwash is an alternative treatment option that has been studied, with some evidence suggesting it can increase salivary flow rates, although the optimal dose and application regimen are not yet established 4.
• Chewing sugar-free gum can also provide oral health benefits, including stimulating saliva flow, which can help to neutralize plaque pH and promote remineralization of early caries-like lesions 5.
• Artificial saliva is another treatment option, although studies have shown that pilocarpine is more effective than artificial saliva for enhancing salivary and lacrimal secretion in patients with Sjögren's syndrome 6.
• Pilocarpine mouthwash has been shown to be safe and effective in elderly patients with xerostomia, with significant reductions in visual analog scale scores and improvements in stimulated salivary flow rate 7.

Benefits and Side Effects of Treatment Options

• Pilocarpine has been shown to have limited activity for the prevention of xerostomia during radiation therapy, but may have increased efficacy in combination with newer forms of radiation therapy 3.
• Pilocarpine mouthwash has been associated with minor side effects, including oral discomfort, in some patients 7.
• Artificial saliva has been shown to be less effective than pilocarpine for enhancing salivary and lacrimal secretion in patients with Sjögren's syndrome, although it may still provide some relief from dry mouth symptoms 6.