What is a Sialagogue?

A sialagogue is a substance or medication that stimulates the production and flow of saliva from the salivary glands. 1, 2

Types of Sialagogues

Gustatory stimulants such as sugar-free acidic candies, lozenges, and xylitol products that trigger saliva production through taste stimulation 1, 3
Mechanical stimulants including sugar-free chewing gum that promote salivary flow through the physical action of chewing 1, 3
These non-pharmacological approaches are recommended as first-line treatment for mild salivary gland dysfunction 1

Muscarinic agonists that stimulate salivary gland function through cholinergic parasympathomimetic action 2
Pilocarpine - a cholinergic parasympathomimetic agent that increases secretion by exocrine glands, including salivary glands 2
Cevimeline - similar mechanism to pilocarpine but may have a better tolerance profile 3, 4
Bethanechol - another cholinergic agent shown to increase stimulated saliva 4
Topical sialogogue sprays containing substances like 1% malic acid have also shown efficacy 5

Pharmacological sialagogues primarily work through cholinergic parasympathomimetic effects, stimulating muscarinic receptors in salivary glands 2, 6
This stimulation leads to increased secretory activity of the exocrine glands, particularly the salivary glands 2
The effect of oral pilocarpine on salivary flow is time-related with onset at 20 minutes, peak effect at 1 hour, and duration of 3-5 hours 2

Treatment of xerostomia (dry mouth) in various conditions:
- Sjögren's syndrome - pharmacological sialagogues like pilocarpine and cevimeline are effective for managing sicca symptoms 1
- Medication-induced dry mouth, such as from antidepressants or stimulants 3, 5
- Radiation-induced xerostomia in head and neck cancer patients 2, 7
- Sicca syndrome related to immune checkpoint inhibitor therapy 1

For mild salivary gland dysfunction:
- Non-pharmacological stimulation with gustatory or mechanical stimulants is the preferred first-line approach 1, 3
For moderate salivary gland dysfunction:
- Pharmacological stimulation with muscarinic agonists (pilocarpine 5mg orally four times daily or cevimeline) may be considered 1, 3
For severe salivary gland dysfunction (no salivary output):
- Saliva substitution with products that have a neutral pH and contain fluoride and electrolytes to mimic natural saliva 1, 3

Baseline evaluation of salivary gland function is recommended before starting treatment 1
Common side effects of pharmacological sialagogues include:
- Excessive sweating (most common) 4
- Nausea 3
- Bronchoconstriction 3
Individual response to sialagogues varies considerably, and trials with different agents may be beneficial to determine patient preference 4, 6
Some sialagogues may have a carryover effect beyond the washout period, suggesting that intermittent treatment could be an alternative to continuous treatment 4

Using multiple sialagogues with different mechanisms of action may produce synergistic effects in managing xerostomia 7
Combined approaches (e.g., non-pharmacological methods plus pharmacological agents) may be more effective for severe cases 8