What are the treatment options for xerostomia?

Treatment of Xerostomia

Begin with a comprehensive medication review to identify and reduce anticholinergic medications, then implement a stepwise treatment algorithm based on residual salivary gland function: non-pharmacological measures for all patients, add gustatory/mechanical stimulants for mild dysfunction, escalate to muscarinic agonists (pilocarpine 5 mg four times daily) for moderate dysfunction, and use saliva substitutes for severe dysfunction or when stimulation fails. 1

Initial Assessment and Cause Identification

Medication review is the critical first step, as drugs are the most common cause of xerostomia, particularly in elderly populations who are typically on multiple medications 2, 3. Focus specifically on:

• Anticholinergic medications (anxiolytics, tricyclic antidepressants, antimuscarinics, antihistamines, decongestants, antiparkinsonians, certain pain medications, and antipsychotics) 4, 1
• Consider dose reduction or switching to alternatives with lower anticholinergic burden when clinically appropriate 1

Assess for non-medication causes including:

• Radiation therapy to head and neck (causes dose-dependent salivary gland dysfunction) 4
• Sjögren's syndrome and other autoimmune conditions 4, 5
• Mouth breathing patterns and anxiety/depression (can manifest as dry mouth independent of hydration status) 1

Measure objective salivary flow rates before initiating treatment, as therapeutic approach depends on actual glandular function rather than subjective symptoms alone 1, 6.

Stepwise Treatment Algorithm

Universal Non-Pharmacological Measures (All Patients)

Dietary and lifestyle modifications 4, 1:

• Consume a low-sucrose diet and avoid caffeine, spicy and highly acidic foods, and tobacco
• Increase water intake throughout the day, preferably fluoridated tap water (though water will not eliminate xerostomia, only provide temporary relief)
• Use alcohol-free mouth rinses only (avoid alcohol-containing mouthwashes)

Dental prophylaxis and caries prevention 4:

• Brush with remineralizing toothpaste
• Use prescription 1.1% sodium fluoride toothpaste as dentifrice or in customized delivery trays
• Regular dental flossing
• Professional dental examination every 6 months minimum, more frequently for those with active caries 4

Mild Glandular Dysfunction: Stimulation Therapy

Non-pharmacological stimulation is the preferred first-line approach 1:

• Gustatory stimulants: Sugar-free acidic candies and lozenges containing xylitol
• Mechanical stimulants: Sugar-free chewing gum
• These work by stimulating residual salivary gland function through taste and mechanical stimulation 7, 8

Moderate Glandular Dysfunction: Pharmacological Stimulation

Muscarinic agonists are indicated when non-pharmacological measures fail 4, 1:

• Pilocarpine 5 mg four times daily (20 mg/day total) is the primary pharmacological option 5

  • FDA-approved for both radiation-induced xerostomia and Sjögren's syndrome
  • Demonstrated statistically significant improvement in global dry mouth symptoms in multiple randomized controlled trials 5
  • Greatest improvement seen in patients with no measurable salivary flow at baseline 5
  • Most common adverse effects: sweating, nausea, rhinitis, diarrhea, chills, flushing, urinary frequency 5
  • Sweating is the most common reason for discontinuation (12% at 10 mg three times daily dose) 5

• Cevimeline is an alternative muscarinic agonist where available 4, 1

Important caveat: Lower doses (2.5 mg four times daily) were not significantly different from placebo in clinical trials 5. The effective dose is 5 mg four times daily.

Severe Dysfunction or Failed Stimulation: Saliva Substitutes

When salivary glands cannot be stimulated or stimulation fails, use artificial saliva products 1, 7, 3:

• Moisture-preserving mouth rinses, sprays, or gels
• Select products with neutral pH containing fluoride and electrolytes to mimic natural saliva composition 1
• Examples include products like Biotene 2
• These provide symptomatic relief but do not address underlying gland dysfunction 7, 6

Additional Therapeutic Considerations

For radiation-induced xerostomia specifically:

• Amifostine administered before each radiation treatment (200 mg/m² over 15-30 minutes) reduces both acute and chronic xerostomia 4
• Reduced overall incidence of grade 2 or higher acute xerostomia from 78% to 51% (P <0.0001) 4
• Chronic xerostomia at 1 year occurred in 34% with amifostine versus 57% without (P=0.002) 4
• This is a preventive measure, not a treatment for established xerostomia

Emerging therapies under investigation include acupuncture, electrostimulation, and gene therapies, though evidence remains limited 7.

Critical Clinical Pitfalls to Avoid

Do not assume dry mouth always indicates dehydration requiring increased fluid intake—thirst and dry mouth are often unrelated to hydration status, particularly in elderly patients 1. While adequate hydration is important, water provides only temporary relief and does not eliminate xerostomia 4.

Monitor for serious complications 4:

• Oral candidiasis (patients with severe xerostomia are at high risk)
• Jaw swelling or pain indicating possible osteonecrosis, particularly in patients with radiation history or bisphosphonate use
• Rapid dental caries progression (radiation-related caries can appear within 3 months of treatment) 4

In patients with cognitive decline or severe xerostomia, oral swabs may be more appropriate than passive drool methods for assessment procedures 1.

Refer to dental specialists experienced in oncology care for patients with radiation-induced xerostomia or complex cases 4.