How to evaluate a complaint of xerostomia (dry mouth)?

From the Guidelines

To evaluate a complaint of xerostomia (dry mouth), begin with a thorough history and physical examination, and then proceed with a baseline evaluation of salivary gland function, as recommended by the EULAR guidelines 1. The evaluation process should include:

• A thorough history focusing on symptom duration, severity, and timing
• Inquiring about current medications, medical conditions, oral hygiene practices, tobacco use, alcohol consumption, and fluid intake patterns
• Physical examination to inspect the oral cavity for signs of dryness and check for salivary gland enlargement or tenderness
• Diagnostic tests such as salivary flow rate measurement, blood tests for autoimmune markers, and occasionally salivary gland imaging or biopsy The therapeutic approach to oral dryness should be driven by the baseline measurement of salivary glandular function, and not by the patient’s subjective feelings, as environmental and personal stressing factors may influence the subjective feeling of dryness, which often does not match with the objective measurement of glandular function 1. According to the EULAR recommendations, the first therapeutic approach to dryness should be symptomatic relief using topical therapies, and systemic therapies may be considered for the treatment of active systemic disease 1. Non-pharmacological stimulation, such as gustatory stimulants and/or mechanical stimulants, may be recommended for patients with mild glandular dysfunction, while pharmacological stimulation with muscarinic agonists may be considered for patients with moderate glandular dysfunction 1. It is essential to identify the underlying cause of xerostomia, as dry mouth can significantly impact quality of life through effects on speech, swallowing, taste, and dental health, and comanagement with a rheumatologist may be necessary for patients with Sjögren’s syndrome or other autoimmune diseases 1.

From the FDA Drug Label

After 6 weeks of treatment, statistically significant global improvement of dry mouth was observed compared to placebo “Global improvement” is defined as a score of 55 mm or more on a 100 mm visual analogue scale in response to the question, “Please rate your present condition of dry mouth (xerostomia) compared with your condition at the start of this study. 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 Patients were evaluated by a measure called global improvement, which is defined as a response of "better" to the question, "Please rate the overall condition of your dry mouth now compared with how you felt before starting treatment in this study."

To evaluate a complaint of xerostomia (dry mouth), the following steps can be taken:

• Assess the patient's global improvement of dry mouth symptoms using a visual analogue scale or a similar measure.
• Evaluate the patient's 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
  • Decreased use of saliva substitutes
• Use a standardized questionnaire to assess the patient's condition, such as the one used in the studies 2 and 3. Note that the evaluation of dry mouth symptoms should be done in a clinical setting and under the guidance of a qualified healthcare professional.

From the Research

Evaluating Complaints of Dry Mouth

To evaluate a complaint of xerostomia (dry mouth), several factors and symptoms should be considered:

• The patient's medical history, including any underlying conditions such as Sjögren's syndrome, or the use of medications that may cause dry mouth as a side effect 4
• The severity of oral dryness, which can be assessed using tools such as the Xerostomia Inventory (XI) scores and Regional Oral Dryness Score (RODI) scores 5
• The patient's salivary flow rate, which can be measured to determine the severity of dry mouth 6, 7

Treatment Options

Various treatment options are available to relieve dry mouth symptoms:

• Topical therapies, such as lozenges, sprays, mouthrinses, gels, oils, chewing gum, or toothpastes, which can be classified into saliva stimulants and saliva substitutes 8
• Pilocarpine, a muscarinic cholinergic agonist, which has been proven to be efficacious in treating radiation-induced xerostomia and symptoms of dry mouth in Sjögren's patients 6, 7
• Integrated mouthcare systems and oral reservoir devices, which may be helpful but require further research to confirm their effectiveness 8

Considerations for Specific Patient Groups

Different subgroups of dry-mouth patients may require tailored interventions:

• Sjögren's syndrome patients may use a wide range of interventions to relieve their oral dryness, and may require more frequent use of interventions compared to other patient groups 5
• Patients using medications may show associations between the total XI score and dry-mouth interventions aimed at the entire mouth 5
• Locally applied interventions, such as mouth gel, may be associated with RODI scores of specific intra-oral regions, such as the anterior tongue 5

Assessing Treatment Efficacy

The efficacy of dry mouth interventions can be assessed by:

• Measuring changes in salivary flow rate 6, 7
• Evaluating symptom relief using questionnaires with visual analog scales or checkboxes 7
• Assessing improvements in quality of life 7