What are the treatments for dry mouth (xerostomia)?

Treatment Options for Dry Mouth (Xerostomia)

The treatment of dry mouth should be guided by the baseline measurement of salivary gland function, with a stepwise approach based on severity that includes non-pharmacological stimulation for mild cases, pharmacological stimulation for moderate cases, and saliva substitution for severe cases with no salivary output. 1

Assessment Before Treatment

Before initiating treatment, it's essential to:

• Measure whole salivary flow rates to determine baseline glandular function
• Rule out unrelated conditions such as candidiasis or burning mouth syndrome
• Consider salivary scintigraphy for further evaluation if needed 1

Treatment Algorithm Based on Severity

For Mild Glandular Dysfunction

1. Non-pharmacological stimulation (first-line approach):
   • Gustatory stimulants: Sugar-free acidic candies, lozenges, xylitol
   • Mechanical stimulants: Sugar-free chewing gum
   • Improve hydration and limit caffeine intake 1

For Moderate Glandular Dysfunction

1. Pharmacological stimulation with muscarinic agonists:
   • Pilocarpine: 5 mg three to four times daily (FDA-approved, available worldwide)
   • Cevimeline: Alternative option with potentially better tolerance profile
   • Note: These medications have shown significant improvements in visual analogue scale dry mouth scores and salivary flow rates, but with frequent adverse events 1, 2

For Severe Dysfunction (No Salivary Output)

1. Saliva substitution (preferred approach):
   • Commercial saliva substitutes (sprays, gels, rinses)
   • Ideal preparations have neutral pH and contain fluoride and electrolytes
   • Oxygenated glycerol triester (OGT) sprays show greater effectiveness compared to electrolyte sprays 1, 3

Additional Management Strategies

For All Patients

• Oral hygiene measures:
  • Fluoride-containing products to prevent dental caries
  • Regular dental check-ups 1, 4

For Moderate to Severe Cases

• Systemic approach:
  • Prednisone 20-40 mg daily for 2-4 weeks, then taper (for immune-related cases)
  • Rheumatology referral for suspected Sjögren's syndrome
  • Dental referral to prevent complications 1

Special Considerations

Medication-Induced Xerostomia

• Review current medications and consider alternatives with fewer anticholinergic effects 4

Cancer Therapy-Related Xerostomia

• More aggressive management may be needed
• Consider specialized protocols for radiation-induced xerostomia 1, 2

Immune Checkpoint Inhibitor-Related Sicca Syndrome

• May require holding immunotherapy
• Consider rheumatology consultation
• Be aware that severe sicca syndrome can lead to dental caries and tooth loss if untreated 1

Common Pitfalls to Avoid

1. Relying solely on subjective symptoms: Environmental and personal stressors may influence the subjective feeling of dryness, which often doesn't match objective measurements 1

2. Overlooking underlying causes: Always investigate potential systemic conditions or medication effects 4

3. Inadequate follow-up: Dry mouth is often a chronic condition requiring ongoing management and monitoring for complications 5

4. Underestimating impact on quality of life: Xerostomia affects eating, speaking, and social interactions, which can lead to malnutrition and decreased quality of life 4

5. Insufficient caries prevention: Patients with xerostomia are at high risk for dental caries and require aggressive preventive measures 1, 4

The evidence suggests that while many interventions provide some degree of symptomatic relief, there is no strong evidence that any single topical therapy is definitively effective for completely relieving dry mouth symptoms 3, 5. Treatment should therefore be tailored to the level of salivary dysfunction and adjusted based on patient response.