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

Treatment Options for Xerostomia (Dry Mouth)

The treatment of xerostomia should follow a stepwise approach based on the degree of salivary gland dysfunction, starting with baseline evaluation of salivary function, followed by non-pharmacological interventions for mild cases, pharmacological stimulation for moderate cases, and saliva substitution for severe cases with no salivary output. 1

Assessment and Diagnosis

• Before initiating treatment, baseline evaluation of salivary gland function should be performed by measuring whole salivary flows, as subjective feelings of dryness may not match objective measurements 1
• Rule out non-Sjögren's related conditions such as candidiasis and burning mouth syndrome 1
• Consider salivary scintigraphy for more detailed assessment of gland function 1

Treatment Algorithm Based on Salivary Function

1. Non-Pharmacological Stimulation (First-Line for Mild Dysfunction)

• For patients with mild glandular dysfunction, non-pharmacological stimulation is the preferred first-line approach 1
• Gustatory stimulants: sugar-free acidic candies, lozenges, and xylitol 1
• Mechanical stimulants: sugar-free chewing gum 1
• The ideal preparation should have a neutral pH and contain fluoride and other electrolytes to mimic natural saliva 1
• All non-pharmacological interventions provide some degree of subjective symptom relief, though evidence doesn't strongly favor one intervention over another 1

2. Pharmacological Stimulation (For Moderate Dysfunction)

• For patients with moderate glandular dysfunction, muscarinic agonists may be considered 1
• Pilocarpine is FDA-approved for treatment of dry mouth from salivary gland hypofunction caused by radiotherapy for head and neck cancer and for symptoms of dry mouth in Sjögren's Syndrome 2
• Typical dosing of pilocarpine is 5 mg three times daily, with potential adjustment to 10 mg three times daily if needed 2
• Randomized controlled trials showed significant improvements in visual analogue scale dry mouth scores and salivary flow rates 1
• Common adverse events include sweating, nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, and asthenia 2
• Sweating is the most common adverse effect leading to treatment discontinuation (≤1% at 5 mg TID; 12% at 10 mg TID) 2
• Cevimeline is another option with a potentially better tolerance profile, though it's not as widely licensed as pilocarpine 1

3. Saliva Substitution (For Severe Dysfunction)

• For patients with no salivary output, saliva substitution should be the preferred therapeutic approach 1
• Available as oral sprays, gels, and rinses 1
• Saliva substitutes are commercially available and should mimic the composition of natural saliva 1
• Different formulations include carmellose sprays, gels, oils, and mucin sprays 3
• Individual preferences vary significantly, so patients should be offered different artificial saliva compounds for a test period 3

Special Considerations

Radiation-Induced Xerostomia

• Amifostine (200 mg/m² IV) administered before radiation therapy has been shown to reduce both acute and chronic xerostomia in head and neck cancer patients 1
• Amifostine reduced grade 2 or higher acute xerostomia from 78% to 51% and chronic xerostomia from 57% to 34% at one year post-treatment 1
• IMRT (Intensity-Modulated Radiation Therapy) significantly reduces xerostomia compared to conventional radiotherapy by sparing major salivary glands 1
• Patients receiving IMRT had significantly lower rates of clinician-rated severe xerostomia (39.3% vs 82.1%) and higher salivary flow rates 1

Medication-Induced Xerostomia

• Consider medication review and possible adjustment of drugs with anticholinergic properties 4, 5
• If possible, reduce doses or switch to alternatives with fewer xerogenic side effects 5
• Implement preventive oral care approaches that address all contributing factors 5

ICU Patients with Thirst/Xerostomia

• A "bundle" of thirst interventions including sprays of cold sterile water, swabs of cold sterile water, and mouth/lip moisturizers can significantly decrease thirst intensity and distress 1
• Frozen gauze pads with normal saline or ice have been shown to be more effective than wet gauze for thirst relief 1
• Avoid lemon-glycerin swabs as they produce acidic pH, dry oral tissues, cause enamel erosion, and exhaust salivary mechanisms 1
• For non-intubated patients on oxygen therapy, heated humidifiers are better than bubble humidifiers for reducing mouth and throat dryness 1

Common Pitfalls and Caveats

• There is often poor correlation between subjective symptoms and objective tests of salivary flow; management should be based primarily on patient symptoms 4
• Lemon-glycerin swabs should be avoided as they can worsen xerostomia over time 1
• The effectiveness of topical therapies varies significantly between individuals; what works for one patient may not work for another 3, 6
• Patients with medication-induced xerostomia need careful monitoring when using cholinergic medications like pilocarpine due to potential side effects including nausea, emesis, and bronchoconstriction 5
• Family members can be involved in providing oral care for patients unable to self-administer treatments 1