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

Treatment Options for Xerostomia (Dry Mouth)

For patients with xerostomia, a stepwise approach is recommended, starting with non-pharmacological interventions for mild cases and progressing to pharmacological options like pilocarpine (5 mg three times daily) for severe cases. 1

Assessment and Management Algorithm

Severity-Based Treatment Approach

Severity	Management Approach
Mild	Non-pharmacological interventions, sugar-free gum/lozenges, increased hydration
Moderate	Continue mild interventions + saliva substitutes
Severe	All above + pilocarpine 5 mg three to four times daily

Non-Pharmacological Interventions (First-Line)

• Hydration and Oral Rinses:

  • Frequent sips of water throughout the day
  • Bland oral rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water) several times daily 1
  • Room humidification, especially during sleep
  • Avoid: Club soda and commercial mouthwashes containing alcohol or astringents as they worsen dryness

• Mechanical Stimulation:

  • Sugar-free chewing gum (preferably xylitol-containing)
  • Sugar-free acidic candies or lozenges to stimulate saliva production 1

• Oral Hygiene:

  • Brushing with ultra-soft toothbrush and prescription-strength fluoride toothpaste within 30 minutes after eating and before bed
  • Flossing at least once daily using waxed floss
  • Regular dental check-ups every 6 months
  • Remineralizing pastes containing calcium and phosphate 1

• Lubrication:

  • Water-based lubricants after cleaning and as needed
  • Animal or plant-based oils for lip care
  • Oral sprays or gels with neutral pH containing fluoride and electrolytes 1

Pharmacological Interventions (For Moderate to Severe Cases)

Saliva Substitutes

• Artificial saliva products when natural saliva production is severely compromised 1
• Most beneficial when natural saliva production cannot be stimulated

Salivary Stimulants

1. Pilocarpine (FDA-approved):

   • Dosage: 5 mg three times daily, may increase to 10 mg three times daily if needed 1, 2
   • Indications: Xerostomia from salivary gland hypofunction caused by:
     • Radiotherapy for head and neck cancer
     • Sjögren's Syndrome 2
   • Efficacy: Increases salivary flow 2-10 fold compared to placebo 3
   • Onset: Rapid increase in salivary flow with peak levels maintained for 1-2 hours 3
   • Common side effects: Sweating, nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness 2

2. Cevimeline:

   • Dosage: 30 mg three times daily 1
   • Advantage: Fewer adverse systemic side effects than pilocarpine
   • Mechanism: Muscarinic agonist similar to pilocarpine

Special Considerations

• Radiation-Induced Xerostomia:

  • Intensity-Modulated Radiation Therapy (IMRT) significantly reduces xerostomia compared to conventional radiotherapy (38% vs. 74% grade 2 or worse xerostomia at 1 year) 1
  • Amifostine (200 mg/m² before each radiation therapy) may decrease acute and late xerostomia in patients undergoing fractionated radiation therapy 1

• Sjögren's Syndrome Patients:

  • Pilocarpine at 5 mg four times daily (20 mg/day) showed significant improvement in dry mouth symptoms 2, 4
  • Higher doses (30 mg/day) may be needed for significant relief of ocular symptoms 4
  • Avoid anticholinergic medications as they worsen sicca symptoms 1

• Medication-Induced Xerostomia:

  • Review and modify medications with anticholinergic properties when possible 5
  • Several hundred medications can cause or exacerbate xerostomia 6

Common Pitfalls to Avoid

• Do not use lemon-glycerin swabs as they produce acidic pH, dry oral tissues, cause enamel erosion, and exhaust salivary mechanisms over time 1

• Do not rely solely on salivary substitutes when residual salivary gland function exists - stimulants are more beneficial in these cases 5

• Do not overlook dental care - xerostomia can lead to accelerated dental decay, making regular dental check-ups essential 6

• Do not assume correlation between symptoms and objective tests - clinical management should be based primarily on patient symptoms rather than salivary flow measurements 5