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

From the Guidelines

For geriatric patients with xerostomia, the first therapeutic approach should be symptomatic relief using topical therapies, as recommended by the European League Against Rheumatism (EULAR) 1. The management of xerostomia in geriatric patients requires a multidisciplinary approach, involving various health professionals, with a central role for specialists in autoimmune diseases 1.

Treatment Options

• Non-pharmacological stimulation, such as frequent sips of water, sugar-free gum or candies, and using a humidifier at night, can help stimulate saliva production.
• Over-the-counter saliva substitutes, like Biotène or XyliMelts, can provide immediate relief.
• Avoiding alcohol-containing mouthwashes, caffeine, tobacco, and alcoholic beverages is crucial, as these can worsen dryness.
• For medication-related dry mouth, consulting with the prescribing physician about possible adjustments to dosage or alternatives is essential.

Pharmacological Stimulation

• In patients with moderate glandular dysfunction, pharmacological stimulation with muscarinic agonists, such as pilocarpine (5mg three times daily) or cevimeline (30mg three times daily), may be considered, as they can stimulate saliva production 1.
• However, these medications have side effects, like sweating, and should be used cautiously in patients with certain conditions, such as uncontrolled asthma or glaucoma.

Oral Hygiene

• Good oral hygiene is essential to prevent complications like tooth decay and oral infections, which are more common with dry mouth.
• Brushing twice daily with fluoride toothpaste, flossing, and regular dental check-ups are crucial for maintaining oral health and quality of life. The EULAR recommendations emphasize the importance of a multidisciplinary approach and the use of topical therapies as the first line of treatment for xerostomia in geriatric patients 1.

From the FDA Drug Label

In a 12 week randomized, double-blind, placebo-controlled study in 207 patients, a statistically significant improvement in mouth dryness occurred in the 5 mg and 10 mg pilocarpine hydrochloride tablet treated patients compared to placebo treated patients. A 12-week, randomized, double-blind, parallel-group, placebo-controlled study was conducted in 256 patients whose mean age was 57 years with a range of 24 to 85 years, and statistically significant global improvement of dry mouth was observed compared to placebo after 6 weeks of treatment with pilocarpine hydrochloride tablets 5 mg four times a day. Another 12 week randomized, double-blind, parallel-group, placebo-controlled study was conducted in 373 patients, and statistically significant global improvement of dry mouth was observed at a dose of 5 mg compared with placebo.

Treatment options for xerostomia (dry mouth) in geriatric patients include:

• Pilocarpine hydrochloride tablets 5 mg four times a day, which has been shown to improve dry mouth symptoms in patients with a mean age of 57 years and a range of 24 to 85 years 2.
• The dose can be adjusted based on the patient's response and tolerance, with some patients requiring a lower dose due to adverse events 2.
• It is essential to monitor patients for common adverse events, such as sweating, nausea, and diarrhea, and adjust the dose accordingly 2.

From the Research

Treatment Options for Xerostomia in Geriatric Patients

The treatment options for xerostomia (dry mouth) in geriatric patients include:

• Good oral hygiene methods 3
• Saliva substitutes containing xylitol 3
• Prescription cholinergic agonists, such as pilocarpine, if appropriate 3, 4, 5
• Topical therapies, including lozenges, sprays, mouthrinses, gels, oils, chewing gum, or toothpastes 6
• Hydration and sialagogues or artificial saliva substitutes 4
• Pilocarpine mouthwash, which has been shown to relieve dry mouth symptoms and improve saliva production with minor side effects 5
• Oxygenated glycerol triester (OGT) saliva substitute spray, which has been shown to be effective compared to an electrolyte spray 6
• Integrated mouthcare systems (toothpaste + gel + mouthwash) and oral reservoir devices, which may be helpful but require further research 6
• Chewing gum, which can increase saliva production in those with residual secretory capacity 6

Causes of Xerostomia

Xerostomia can be caused by:

• Medication use, particularly anticholinergic medications and diuretics 3, 4
• Polypharmacy 3
• Dehydration 3, 4
• Alcohol and caffeine intake 3
• Systemic diseases, such as Sjögren's disease, diabetes mellitus, nephritis, and thyroid dysfunction 3, 4
• Radiation therapy 4
• Autoimmune diseases, such as Sjögren's syndrome 4, 6

Importance of Early Intervention

Early intervention for dry mouth problems is crucial to prevent the deleterious consequences of this disorder in elderly people, including dental caries, periodontal disease, and infections 3, 4, 7. Clinicians must be aware of dry mouth problems in older patients and be prepared to provide a diagnosis and administer treatment to protect a patient's oropharyngeal health and quality of life 7.