What are the treatments for dry mouth (xerostomia)?

Treatment of Dry Mouth (Xerostomia)

Treatment should follow a severity-based algorithm starting with objective measurement of salivary gland function, then progressing from non-pharmacological stimulation for mild dysfunction, to pharmacological muscarinic agonists for moderate dysfunction, to saliva substitutes for severe dysfunction. 1, 2

Mandatory First Step: Assess Salivary Function

• Measure whole salivary flow rates objectively before initiating any treatment, as subjective feelings of dryness frequently do not correlate with actual glandular function and can be influenced by environmental and psychological factors. 1, 2
• Rule out unrelated conditions including candidiasis and burning mouth syndrome before attributing symptoms to salivary dysfunction. 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
• Employ mechanical stimulants such as sugar-free chewing gum to increase saliva production. 1, 2
• These interventions are preferred as first-line therapy because glandular function can still be stimulated in patients with mild dysfunction. 1
• Important caveat: No strong evidence demonstrates that one non-pharmacological intervention is superior to another, though all provide some degree of symptom relief. 1, 3

Moderate Glandular Dysfunction: Pharmacological Stimulation

• Consider muscarinic agonists (pilocarpine or cevimeline) for patients with moderate salivary dysfunction not responding adequately to non-pharmacological measures. 1, 2
• Pilocarpine 5 mg orally four times daily is the preferred agent, as it is licensed worldwide for xerostomia treatment. 1, 2
• Cevimeline may offer a better tolerance profile compared to pilocarpine. 2
• Critical monitoring required: These agents cause frequent adverse effects including excessive sweating, nausea, and bronchoconstriction, necessitating careful patient selection and monitoring. 2
• Pivotal randomized controlled trials demonstrated significant improvements in visual analogue scale dry mouth scores and salivary flow rates. 1

Severe Glandular Dysfunction: Saliva Substitution

• Use saliva substitutes as the primary approach when salivary output is minimal or absent, as stimulation is ineffective without residual glandular function. 1, 2
• Select products with neutral pH containing fluoride and electrolytes to mimic natural saliva composition, available as oral sprays, gels, and rinses. 1, 2
• Oxygenated glycerol triester (OGT) spray demonstrates superior effectiveness compared to aqueous electrolyte sprays, with approximately 2 points improvement on a 10-point visual analogue scale. 3

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 for dental protection. 2, 4
• Apply moisture-preserving mouth rinses or sprays for sustained relief. 4

Critical Dental Complications Prevention

• Prescribe fluoride rinses or gels for all dentate patients with xerostomia, as untreated severe dry mouth leads to dental caries and eventual tooth loss. 4, 5
• Mandate regular dental monitoring for all patients with persistent xerostomia to prevent irreversible dental damage. 4, 5

When to Escalate Care

• Refer to specialty consultation when symptoms are severe, persistent despite appropriate management, or significantly affecting quality of life. 2, 4
• Consider rheumatology referral if sicca syndrome features develop beyond simple xerostomia, suggesting possible Sjögren's syndrome. 4, 5
• Refer for dental evaluation when signs of dental complications appear. 2, 4

Common Pitfalls to Avoid

• Do not base treatment selection solely on patient-reported symptoms without objective salivary flow measurement, as this leads to inappropriate therapy choices. 1, 5
• Do not use salivary stimulants in patients with severe glandular dysfunction, as they require residual secretory capacity to be effective. 1, 2
• Do not overlook medication review, as anticholinergic drugs are the most common reversible cause of xerostomia. 6
• Recognize that salivary substitutes provide only short-duration relief due to removal during swallowing and do not replicate the protective functions of natural saliva. 7