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

Treatment Options for Dry Mouth (Xerostomia)

The treatment of dry mouth should be guided by baseline salivary gland function measurement and follows a stepwise approach of non-pharmacological stimulation, pharmacological stimulation, or saliva substitution depending on the severity of glandular dysfunction. 1

Assessment Before Treatment

• Baseline evaluation of salivary gland function should be performed by measuring whole salivary flows before initiating treatment, as subjective feelings of dryness may not match objective measurements 1
• Severity can be classified as mild (G1), moderate (G2), or severe (G3) based on symptoms and impact on daily life 2
• Always rule out conditions unrelated to salivary dysfunction such as candidiasis or burning mouth syndrome 1

Treatment Algorithm Based on Severity

For Mild Glandular Dysfunction (First-Line)

• Non-pharmacological salivary stimulation is recommended as the preferred first-line approach: 1
  • Use gustatory stimulants (sugar-free acidic candies, lozenges, xylitol) 1
  • Use mechanical stimulants (sugar-free chewing gum) 1
  • Optimize hydration by increasing water intake and limiting caffeine consumption 3
  • Implement dietary modifications by avoiding crunchy, spicy, acidic, or hot foods 3

For Moderate Glandular Dysfunction (Second-Line)

• Pharmacological stimulation with muscarinic agonists may be considered: 1
  • Pilocarpine (5 mg orally three to four times daily) - FDA approved for dry mouth from salivary gland hypofunction caused by radiotherapy for head and neck cancer and for Sjögren's Syndrome 4
  • Cevimeline - has a similar mechanism but may have a better tolerance profile 1
  • Monitor for adverse effects including sweating (most common reason for discontinuation), nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, and asthenia 4

For Severe Glandular Dysfunction (No Salivary Output)

• Saliva substitution should be the preferred approach: 1
  • Use saliva substitutes with neutral pH containing fluoride and electrolytes to mimic natural saliva 2
  • Available as oral sprays, gels, and rinses 1
  • Consider specialized toothpastes and rinses designed for dry mouth 3

Special Considerations

• For medication-induced xerostomia, consider altering medications with anticholinergic properties when possible 5, 6
• Patients with Sjögren's Syndrome showed statistically significant improvement with pilocarpine 5 mg four times daily compared to placebo in clinical trials 4
• Untreated severe dry mouth can lead to dental caries and eventually tooth loss, emphasizing the importance of prompt management 2
• Include a dentist on the treatment team for patients with persistent dry mouth 7

Monitoring and Follow-up

• Assess response to therapy based on symptomatic improvement in:
  • Ability to speak without water 4
  • Ability to sleep without drinking water 4
  • Ability to swallow food without drinking 4
  • Reduced need for supplemental oral comfort agents 4

Pitfalls and Caveats

• There is little correlation between patient symptoms and objective tests of salivary flow; therefore, clinical management should be based primarily on patient symptoms 6
• Muscarinic agonists like pilocarpine have significant side effects and are contraindicated in certain conditions including uncontrolled asthma, acute iritis, and narrow-angle glaucoma 8
• No evidence suggests that one non-pharmacological intervention is more effective than another for mild dry mouth 1
• Tolerance to the pharmacological effects of pilocarpine has not been observed during prolonged administration for up to 5 months 8