How is xerostomia managed and treated?

Management and Treatment of Xerostomia

Begin with a comprehensive medication review to identify and reduce anticholinergic burden, as medications are the most common cause of xerostomia, then implement a stepwise approach starting with non-pharmacological measures, advancing to salivary stimulants for patients with residual gland function, and reserving saliva substitutes for severe dysfunction. 1, 2, 3

Step 1: Identify and Address Underlying Causes

Medication Review (Most Critical Step)

• Conduct a thorough medication review focusing on anticholinergic drugs including anxiolytics, antidepressants (particularly tricyclics), antimuscarinics, antihistamines, decongestants, antiparkinsonians, pain medicines, and antipsychotics 1, 2
• Consider dose reduction or switching to alternatives with lower anticholinergic effects when clinically appropriate 2, 3
• Note that polypharmacy significantly increases xerostomia risk 1, 4

Assess Other Contributing Factors

• Evaluate for dehydration, alcohol and caffeine intake (both have diuretic effects) 1, 5
• Screen for systemic diseases: Sjögren's syndrome, diabetes, chronic kidney disease, thyroid dysfunction 1, 4
• Assess for mouth breathing patterns and anxiety/depression, which can manifest as dry mouth independent of hydration status 2

Step 2: Implement Universal Supportive Measures (All Patients)

Oral Hygiene Protocol

• Brush teeth twice daily with soft toothbrush using fluoride-containing, non-foaming toothpaste (Bass or modified Bass method) 1
• Use prescription 1.1% sodium fluoride toothpaste as dentifrice or in customized delivery trays 2
• Rinse mouth with alcohol-free mouthwash at least four times daily for approximately 1 minute 1, 2
• Replace toothbrush monthly to reduce infection risk 1

Dietary and Lifestyle Modifications

• Consume a low-sucrose diet and avoid caffeine, spicy foods, highly acidic foods, hot drinks, and tobacco 5, 2
• Increase water intake throughout the day, preferably fluoridated tap water 5, 2
• Drink ample fluids to keep mouth moist 1
• Avoid alcohol-containing products 1

Topical Measures

• Lubricate lips with sterile vaseline/white paraffin, lip balm, or lip cream (avoid chronic vaseline use as it promotes mucosal dehydration and infection risk) 1
• Inspect oral mucosa daily for complications 1

Step 3: Determine Salivary Gland Function

Measure whole salivary flow rates before initiating treatment, as therapeutic approach depends on objective glandular function rather than subjective symptoms alone 2, 3

Step 4: Treatment Based on Gland Function

For Mild to Moderate Glandular Dysfunction (Residual Function Present)

Salivary stimulants are more beneficial than substitutes when residual gland function exists 3

Non-Pharmacological Stimulation (First-Line)

• Gustatory stimulants: sugar-free acidic candies and lozenges containing xylitol 2, 4
• Mechanical stimulants: sugar-free chewing gum 5, 2
• These mechanically stimulate saliva production 5

Pharmacological Stimulation (Second-Line)

• Pilocarpine 5 mg three to four times daily is the primary systemic sialagogue 5, 6
  • FDA-approved dosing: 5 mg four times daily (20 mg/day) for Sjögren's syndrome showed statistically significant global improvement after 6 weeks 6
  • For radiation-induced xerostomia: 5 mg three times daily, with option to escalate to 10 mg three times daily if tolerated 6
  • Most common adverse effects: sweating (most common cause of discontinuation at 12% for 10 mg dose), nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, asthenia 6
  • Use with caution in patients with cardiovascular disease, asthma, or narrow-angle glaucoma 5
• Cevimeline is an alternative muscarinic agonist where available 5, 2

For Severe Dysfunction or Failed Stimulation

Use saliva substitutes including moisture-preserving mouth rinses, sprays, or gels 5, 2

• Select products with neutral pH containing fluoride and electrolytes to mimic natural saliva composition 2
• Water sips can provide temporary relief 5

For Moderate to Severe Symptoms with Inflammatory Component

• Consider prednisone, particularly if inflammatory etiology suspected 5

Step 5: Dental Referral and Monitoring

Routine Monitoring

• Dental examination every 6 months minimum, or more frequently for patients with xerostomia or new caries lesions 1, 2
• Regular reassessment of symptoms to adjust treatment as needed 5

Immediate Referral Indications

• Severe xerostomia causing functional impairment in eating, speaking, or denture tolerance 5
• Signs of dental caries, periodontal disease, or oral candidiasis requiring specialized treatment 5
• Jaw swelling or pain (possible osteonecrosis), particularly in patients with radiation history or bisphosphonate use 5, 2
• Head and neck cancer survivors require automatic referral to dental professionals experienced in oncology care 5

Special Considerations for High-Risk Populations

Radiation Therapy Patients

• Pre-radiation dental evaluation must be completed at least 2 weeks before starting radiotherapy 1
• IMRT and salivary gland-sparing techniques are associated with dose-dependent recovery of function over time 1
• Radiation-related caries can appear within first 3 months post-treatment 1

Patients with Dysphagia

• Conduct clinical swallow examination or instrumental swallow evaluation to assess function 5
• Consider neuromuscular electrical stimulation combined with conventional swallowing therapy 5
• Refer to speech-language pathologist for specialized assessment 5

Critical 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 2
• Do not delay referral when severe xerostomia is already causing functional impairment 5
• Do not use vaseline/white paraffin chronically on lips as it promotes mucosal dehydration and increases infection risk 1
• Do not start interdental cleaning during cancer therapy if patient not previously using it regularly, as it can break epithelial barrier causing gingival bleeding 1
• Monitor for oral candidiasis and treat as clinically indicated 1