What are the management options for dry tongue (xerostomia)?

Management of Dry Tongue (Xerostomia)

The management of dry tongue (xerostomia) should follow a stepped approach based on severity, starting with non-pharmacological interventions like saliva substitutes and dietary modifications, progressing to pharmacological stimulants like pilocarpine for moderate to severe cases, and implementing aggressive preventive dental care to avoid complications. 1, 2

Assessment and Classification

Before initiating treatment, it's essential to:

• Measure salivary flow rates to determine baseline glandular function
• Rule out conditions like candidiasis or burning mouth syndrome
• Classify severity: mild, moderate, or severe dysfunction

Management Algorithm Based on Severity

Mild Salivary Gland Dysfunction

• Non-pharmacological stimulation:

  • Sugar-free acidic candies and sugar-free gum
  • Xylitol-containing products
  • Increased hydration
  • Limited caffeine intake 2

• Dietary modifications:

  • Avoid alcohol (including alcohol-containing mouthwashes)
  • Avoid spicy, abrasive, and highly acidic foods
  • Minimize intake of sticky and sugar-containing foods/drinks
  • Avoid caffeine and tobacco 1, 2

• Topical measures:

  • Saliva substitutes (sprays, gels, rinses) with neutral pH and fluoride content
  • Alcohol-free mouth rinses
  • Water-soluble lubricants for oral cavity 1, 2

Moderate Salivary Gland Dysfunction

• Continue all measures for mild dysfunction
• Pharmacological stimulation:
  • Pilocarpine 5 mg three to four times daily (first-line)
  • Cevimeline as an alternative option
  • Monitor for side effects, particularly excessive sweating 2, 3

Severe Salivary Gland Dysfunction

• Continue all previous measures
• Intensive saliva substitution:
  • More frequent application of saliva substitutes
  • Oxygenated glycerol triester (OGT) sprays (more effective than electrolyte sprays) 2
• Consider systemic approach:
  • For suspected autoimmune etiology (e.g., Sjögren's syndrome): prednisone 20-40 mg daily for 2-4 weeks with taper and rheumatology referral 2

Oral Hygiene Protocol

• Daily oral care plan:

  • Brush with prescription-strength fluoride toothpaste
  • Use remineralizing pastes containing calcium and phosphate
  • Brush within 30 minutes after eating and before bed
  • Rinse with bland solution (1 tsp salt, 1 tsp baking soda in 4 cups water) several times daily
  • Floss at least once daily 1

• Denture care (if applicable):

  • Remove dentures before brushing
  • Clean dentures after meals and at bedtime
  • Remove for long periods (at least 8 hours per 24 hours) 1

Prevention of Complications

• Dental caries prevention:

  • Regular professional dental care every 6 months
  • Use of prescription 1.1% sodium fluoride toothpaste
  • Consider fluoride trays for severe cases 1

• Candidiasis management:

  • Monitor for signs of oral fungal infections
  • Consider systemic fluconazole and/or clotrimazole troches for treatment 1

Special Considerations

• Cancer patients:

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

• Elderly patients:

  • Review medication list for drugs with anticholinergic effects
  • Consider drug modifications when possible 4, 5

• Sjögren's syndrome:

  • More intensive management often required
  • Rheumatology referral for systemic management 2

Monitoring and Follow-up

• Regular dental check-ups every 6 months
• Assessment of salivary flow rates to evaluate treatment efficacy
• Monitoring for oral complications (caries, periodontal disease, candidiasis)
• Adjustment of treatment based on symptom control and patient satisfaction

The management of xerostomia requires a comprehensive approach that addresses both symptom relief and prevention of complications. While many treatments provide only temporary relief, a consistent and thorough management strategy can significantly improve quality of life for patients with dry tongue.