What are the treatments for dry mouth (xerostomia)?

Treatment of Dry Mouth (Xerostomia)

Treatment should be guided by objective measurement of salivary gland function, not subjective symptoms, and follows a severity-based algorithm: non-pharmacological stimulation for mild dysfunction, pharmacological stimulation with muscarinic agonists (pilocarpine or cevimeline) for moderate dysfunction, and saliva substitutes for severe dysfunction. 1, 2

Mandatory First Step: Assess Salivary Function

• Measure whole salivary flow rates before initiating any treatment, as subjective feelings of dryness often do not correlate with objective glandular function. 1, 2
• Rule out unrelated conditions such as candidiasis or burning mouth syndrome before attributing symptoms to xerostomia. 1
• Salivary scintigraphy may be considered as an additional assessment tool. 1

Treatment Algorithm Based on Severity

Mild Glandular Dysfunction: Non-Pharmacological Stimulation (First-Line)

• Use gustatory stimulants including sugar-free acidic candies, lozenges, or xylitol products to stimulate residual salivary function. 1, 2
• Use mechanical stimulants such as sugar-free chewing gum to promote saliva production in patients with remaining glandular capacity. 1, 2
• Select products with neutral pH containing fluoride and electrolytes to mimic natural saliva composition. 1
• No single non-pharmacological intervention has proven superior to another, so patient preference should guide selection within this category. 2

Moderate Glandular Dysfunction: Pharmacological Stimulation

• Prescribe pilocarpine 5 mg orally four times daily as the primary pharmacological stimulant, which is licensed worldwide for xerostomia. 1, 2
• Consider cevimeline as an alternative muscarinic agonist, which may have a better tolerance profile than pilocarpine. 2, 3
• Monitor closely for adverse effects including excessive sweating, nausea, and bronchoconstriction, particularly in older adults. 2
• Pilocarpine demonstrates significant improvements in visual analogue scale dry mouth scores and salivary flow rates in randomized controlled trials. 1

Severe Glandular Dysfunction: Saliva Substitution

• Use saliva substitutes as the primary approach when no salivary output is present, as stimulation is ineffective without residual glandular function. 2, 4
• Select products available as oral sprays, gels, or rinses with neutral pH containing fluoride and electrolytes. 1, 2
• Saliva substitutes containing xylitol provide temporary relief while offering protection against dental caries. 2

Universal Supportive Measures (All Severity Levels)

• Increase water intake throughout the day and limit caffeine consumption, which exacerbates dry mouth symptoms. 2, 4
• Avoid crunchy, spicy, acidic, or hot foods that worsen oral discomfort. 2, 4
• Use specialized toothpastes and mouth rinses designed for xerostomia that are less irritating and contain fluoride. 2, 4
• Prescribe fluoride rinses or gels for all dentate patients to prevent dental caries, a major complication of chronic xerostomia. 4, 5

Critical Pitfalls and Monitoring

• Do not rely on patient-reported symptoms alone to guide treatment selection, as environmental and personal stressors influence subjective dryness perception independent of actual glandular function. 1
• Untreated severe dry mouth leads to dental caries and eventual tooth loss, requiring proactive dental referral and regular monitoring. 6, 4
• Salivary substitutes have short duration of effect due to swallowing and do not provide the protective immunological roles of natural saliva. 3
• Muscarinic agonists are contraindicated in patients with uncontrolled asthma, narrow-angle glaucoma, or acute iritis due to cholinergic effects. 2

When to Escalate Care

• Refer to specialty care when symptoms are severe, persistent despite management strategies, or significantly affecting quality of life. 2, 4
• Consider rheumatology referral if sicca syndrome features develop, suggesting possible Sjögren's syndrome. 6, 4
• Dental referral is essential for patients showing signs of dental complications from chronic xerostomia. 2, 6

Medication Review

• Conduct a comprehensive medication review to identify and potentially eliminate drugs with anticholinergic effects, as medication use is the most common cause of dry mouth in the general population and older adults. 7, 8
• Consider switching to alternative formulations with lower anticholinergic burden when clinically appropriate. 6