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

Treatment Options for Dry Mouth (Xerostomia)

The treatment of dry mouth should be guided by baseline measurement of salivary gland function and follows a stepwise approach based on severity, starting with non-pharmacological methods for mild cases, adding pharmacological stimulants for moderate cases, and using saliva substitutes for severe cases. 1, 2

Assessment Before Treatment

• Baseline evaluation of salivary gland function by measuring whole salivary flows is essential before starting treatment, as subjective feelings of dryness may not match objective measurements 3
• Always rule out conditions unrelated to salivary dysfunction such as candidiasis or burning mouth syndrome 3
• Salivary scintigraphy may be considered as an additional diagnostic tool 3

Treatment Algorithm Based on Severity

For Mild Glandular Dysfunction:

• Non-pharmacological salivary stimulation is the preferred first-line approach 3:
  • Gustatory stimulants (sugar-free acidic candies, lozenges, xylitol) 3, 1
  • Mechanical stimulants (sugar-free chewing gum) 3
  • Improve hydration and limit caffeine intake 1

For Moderate Glandular Dysfunction:

• Pharmacological stimulation with muscarinic agonists 3, 2:
  • Pilocarpine (5 mg three to four times daily) - FDA approved for dry mouth in Sjögren's syndrome and radiation-induced xerostomia 4
  • Cevimeline - may have better tolerance profile than pilocarpine 1, 2
  • Monitor for side effects including sweating, nausea, rhinitis, diarrhea, and dizziness 4

For Severe Glandular Dysfunction (No Salivary Output):

• Saliva substitution should be the preferred approach 1, 2:
  • Use products with neutral pH containing fluoride and electrolytes to mimic natural saliva 3
  • Available as oral sprays, gels, and rinses 3, 2
  • Xylitol-containing oral sprays provide temporary relief while offering protection against dental caries 1, 2

Additional Supportive Measures

• Dietary modifications: avoid crunchy, spicy, acidic, or hot foods that may exacerbate discomfort 3, 1
• Specialized toothpastes and rinses designed for dry mouth that are less irritating and contain fluoride 1
• Regular sips of water throughout the day 5
• For dentate patients, prescribe fluoride rinse or gel to reduce caries risk 5, 6

Important Clinical Considerations

• Untreated severe dry mouth can lead to dental caries and eventually tooth loss, emphasizing the importance of prompt and effective management 3, 2
• Saliva substitutes provide symptomatic relief but do not address underlying disease processes 2, 7
• The duration of effect for salivary substitutes is typically short due to swallowing 7
• There is limited strong evidence that any single topical therapy is significantly more effective than others for relieving dry mouth symptoms 6
• Oxygenated glycerol triester (OGT) spray may be more effective than aqueous electrolyte sprays 6
• Integrated mouthcare systems (toothpaste + gel + mouthwash) show promising results but require further research 6

When to Consider Specialist Referral

• Dental referral is recommended for patients with signs of dental complications from chronic dry mouth 3, 1
• Rheumatology referral may be beneficial for patients with suspected Sjögren's syndrome 3, 2
• Consider referral when symptoms are severe, persistent despite management strategies, or significantly affecting quality of life 3, 8