What medications are used to treat dry mouth (xerostomia)?

Treatment of Dry Mouth (Xerostomia)

For dry mouth treatment, a stepwise approach based on salivary gland function severity is recommended, starting with non-pharmacological methods for mild dysfunction, progressing to pharmacological stimulants for moderate dysfunction, and using saliva substitutes for severe cases with no salivary output. 1, 2

Assessment Before Treatment

• Baseline evaluation of salivary gland function by measuring whole salivary flows is recommended before starting treatment 1, 3
• Rule out conditions unrelated to salivary dysfunction such as candidiasis or burning mouth syndrome 1
• Classify severity as mild (G1), moderate (G2), or severe (G3) based on symptoms and impact on daily life 3

Treatment Algorithm Based on Severity

First-Line: Non-Pharmacological Approaches (Mild Dysfunction)

• Increase water intake and limit caffeine consumption which can worsen dry mouth symptoms 2
• Use gustatory stimulants such as sugar-free acidic candies, lozenges, or xylitol 1, 2
• Employ mechanical stimulants like sugar-free chewing gum to stimulate saliva production 1, 2
• Implement dietary modifications by avoiding crunchy, spicy, acidic, or hot foods that may exacerbate discomfort 1, 2

Second-Line: Pharmacological Stimulation (Moderate Dysfunction)

• Muscarinic agonists such as pilocarpine and cevimeline are FDA-approved for treating dry mouth 1, 4
• Pilocarpine is indicated for dry mouth from salivary gland hypofunction caused by radiotherapy for head and neck cancer and for Sjögren's Syndrome 4
• Recommended dosage for pilocarpine is 5 mg three times daily, which can be increased to 10 mg three times daily if needed 4
• Cevimeline may have a better tolerance profile than pilocarpine 1, 5

Third-Line: Saliva Substitution (Severe Dysfunction/No Salivary Output)

• Saliva substitutes should be the preferred approach for patients with no salivary output 1, 2
• Use products with neutral pH containing fluoride and electrolytes to mimic natural saliva 2, 3
• Available as oral sprays, gels, and rinses 1, 6

Efficacy and Side Effects

• Pilocarpine significantly improves global assessment of dry mouth and specific symptoms like mouth discomfort and ability to speak without water 4
• In clinical trials, pilocarpine increased salivary flow rates 2-10 fold higher than placebo 7
• Common side effects of pilocarpine include sweating, nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, and asthenia 4, 8
• Sweating is the most common adverse effect causing treatment discontinuation (≤1% at 5 mg TID; 12% at 10 mg TID) 4

Special Considerations

• For cancer patients receiving immunotherapy who develop dry mouth, specific management guidelines for immunotherapy-related sicca syndrome should be followed 1
• Severe sicca syndrome, if left untreated, can result in dental caries and eventually tooth loss 1, 6
• Elderly patients are at higher risk of xerostomia due to increased medication use and polypharmacy 5, 6
• Pharmacological stimulants require careful monitoring in older adults due to potential side effects 2, 5

Monitoring and Follow-up

• Dental referral is recommended for patients with signs of dental complications from chronic dry mouth 1, 6
• Rheumatology referral may be beneficial, especially for patients with suspected Sjögren's syndrome 1
• Consider dose adjustments based on patient response and tolerability 4, 8