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

Treatment Options for Dry Mouth (Xerostomia)

The treatment of dry mouth should be based on the baseline measurement of salivary gland function, with a stepwise approach starting with non-pharmacological methods for mild cases and progressing to pharmacological interventions for moderate to severe cases. 1

Assessment Before Treatment

• Baseline evaluation of salivary gland function by measuring whole salivary flows is recommended before starting treatment to determine the appropriate therapeutic approach 1, 2
• Rule out SjS-unrelated conditions such as candidiasis and burning mouth syndrome 1
• Salivary scintigraphy may be considered for more detailed assessment 1

Treatment Algorithm Based on Severity

For Mild Glandular Dysfunction:

• Non-pharmacological glandular stimulation is the preferred first-line approach: 1
  • Gustatory stimulants: sugar-free acidic candies, lozenges, xylitol 1, 3
  • Mechanical stimulants: sugar-free chewing gum 1, 3
  • Improve hydration and limit caffeine intake 1, 2
  • Avoid tobacco, alcohol (including alcohol-containing mouthwash), spicy foods, and acidic/citric liquids 1

For Moderate Glandular Dysfunction:

• Pharmacological stimulation with muscarinic agonists may be considered: 1
  • Pilocarpine (5-10 mg three to four times daily) - FDA approved for treatment of symptoms of dry mouth from salivary gland hypofunction 4
  • Cevimeline (not available worldwide) 1
  • Both medications have shown statistically significant improvements in global assessment of dry mouth, ability to speak without water, and reduced need for supplemental oral comfort agents 4

For Severe Glandular Dysfunction (No Salivary Output):

• Saliva substitution should be the preferred therapeutic approach: 1
  • Saliva substitutes in the form of oral sprays, gels, and rinses 1, 5
  • Ideal preparations should have a neutral pH and contain fluoride and other electrolytes to mimic natural saliva 2
  • Oxygenated glycerol triester (OGT) saliva substitute spray has shown evidence of effectiveness compared to electrolyte spray 5

Special Considerations

• For cancer patients who developed dry mouth following immunotherapy, topical measures should be used initially, with systemic steroids (prednisone 20-40 mg daily for 2-4 weeks, then taper) considered for those with moderate to severe symptoms when topical measures are ineffective 1
• Dental referral is important as severe xerostomia can lead to dental caries and eventual tooth loss if left untreated 1, 2
• For patients with Sjögren's syndrome, pilocarpine has shown statistically significant global improvement of dry mouth at doses of 5 mg four times daily 4

Common Pitfalls and Caveats

• Patient's subjective feelings of dryness often do not match with objective measurements of glandular function 1
• Muscarinic agonists (pilocarpine, cevimeline) have a high frequency of adverse events including sweating, nausea, rhinitis, diarrhea, chills, flushing, and dizziness 4
• The most common adverse experience causing withdrawal from pilocarpine treatment is sweating (≤1% at 5 mg t.i.d.; 12% at 10 mg t.i.d.) 4
• Saliva substitutes provide only temporary relief as they are removed during swallowing, and they don't provide the protective roles of natural saliva 6, 7
• There is limited evidence that any topical therapy is definitively effective for relieving dry mouth symptoms 5, 8

By following this stepwise approach based on salivary gland function assessment, most patients with dry mouth can achieve significant symptom relief and improved quality of life.