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

Treatment Options for Xerostomia (Dry Mouth)

The treatment of dry mouth should be based on the degree of salivary gland dysfunction, starting with baseline evaluation of salivary flow rates, followed by a stepwise approach of non-pharmacological stimulation, pharmacological stimulation, or saliva substitution depending on remaining glandular function. 1

Assessment Before Treatment

• Measure whole salivary flows (unstimulated and stimulated) to determine baseline glandular function
• Rule out SjS-unrelated conditions such as candidiasis and burning mouth syndrome
• Consider salivary scintigraphy for additional evaluation 1

Treatment Algorithm Based on Salivary Gland Function

For Mild Glandular Dysfunction

1. Non-pharmacological stimulation (first-line):
   • Gustatory stimulants: sugar-free acidic candies, lozenges, xylitol
   • Mechanical stimulants: sugar-free chewing gum
   • Improve hydration and limit caffeine intake 1
   • Dietary modifications to avoid crunchy, spicy, acidic, or hot foods/drinks 1

For Moderate Glandular Dysfunction

1. Pharmacological stimulation with muscarinic agonists:

   • Pilocarpine: 5 mg three times daily (can be adjusted to 5-10 mg TID) 1, 2
   • Cevimeline: alternative with potentially better tolerance profile 1
   • Consider holding if adverse effects occur (sweating is most common side effect causing discontinuation) 2

2. If pharmacological stimulation fails or is contraindicated:

   • Use saliva substitutes (sprays, gels, rinses)
   • Consider prednisone 20-40 mg daily for 2-4 weeks, then taper 1

For Severe Glandular Dysfunction (No Salivary Output)

1. Saliva substitution (preferred approach):
   • Oral sprays, gels, and rinses with neutral pH containing fluoride and electrolytes
   • Regular sips of water throughout the day 1, 3
   • Consider referral to rheumatology and dental specialists 1
   • Consider inpatient care for severe cases 1

Special Considerations

For Sjögren's Syndrome Patients

• Pilocarpine has shown statistically significant global improvement of dry mouth at doses of 5 mg four times daily (20 mg/day) 2
• After 6 weeks of treatment, significant improvements were observed in:
  • 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 2

For Immunotherapy-Related Sicca Syndrome

• Hold immunotherapy for moderate to severe symptoms
• Use topical measures first, then add systemic therapy if needed
• Consider prednisone 20-40 mg daily for 2-4 weeks, then taper
• Be aware that severe sicca syndrome can lead to dental caries and tooth loss if untreated 1

Pitfalls and Caveats

1. Subjective vs. Objective Assessment: Don't rely solely on patient's subjective feelings of dryness, as environmental and personal stressors may influence perception without matching objective glandular function 1

2. Safety Profile of Muscarinic Agonists: Be aware of common adverse events with pilocarpine including sweating (most common reason for discontinuation), nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, and asthenia 2

3. Duration of Effect: Saliva substitutes have short-term effects due to swallowing and don't provide the protective roles of natural saliva 4

4. Evidence Quality: Most systematic reviews on dry mouth management are of "critically low" quality, with limited high-quality evidence supporting specific interventions 5

5. Fluoride Consideration: For dentate patients with dry mouth, prescribe fluoride rinse or gel to reduce caries risk 3