How is xerostomia treated?

Treatment of Xerostomia

Begin with non-pharmacological interventions including increased water intake, dietary modifications, and topical saliva substitutes, then escalate to systemic sialagogues (pilocarpine 5 mg three to four times daily or cevimeline) for moderate to severe symptoms when residual salivary gland function exists. 1, 2, 3

Initial Assessment and Cause Identification

• Conduct a comprehensive medication review focusing on anticholinergic burden, as medications are the most common reversible cause of xerostomia, particularly in elderly populations 2, 4
• Consider dose reduction or switching to alternatives with lower anticholinergic effects (antidepressants, antihistamines, antimuscarinics, anxiolytics, and antiparkinsonians are common culprits) 5, 2
• Measure whole salivary flow rates before initiating treatment, as therapeutic approach depends on objective glandular function rather than subjective symptoms alone 2
• Evaluate for underlying systemic diseases including Sjögren's syndrome, diabetes, and history of head/neck radiation 6, 7

First-Line Non-Pharmacological Management

Hydration and Dietary Modifications

• Optimize hydration by increasing water intake (preferably fluoridated tap water) and limiting caffeine, which worsens dry mouth symptoms 1, 2
• Avoid crunchy, spicy, acidic, or hot foods/drinks that exacerbate discomfort 1
• Implement a low-sucrose diet and eliminate tobacco use 2

Topical Measures for Mild Glandular Dysfunction

• Use saliva substitutes including moisture-preserving mouth rinses, sprays, or gels with neutral pH containing fluoride and electrolytes to mimic natural saliva 1, 2
• Employ gustatory stimulants such as sugar-free acidic candies and lozenges containing xylitol 2
• Utilize mechanical stimulants like sugar-free chewing gum to stimulate residual salivary function 1, 2
• Take frequent water sips throughout the day 1

Oral Hygiene Protocol

• Use alcohol-free mouth rinses only (alcohol-containing products worsen xerostomia) 2
• Brush with remineralizing toothpaste or prescription 1.1% sodium fluoride toothpaste 2
• Schedule dental examinations every 6 months (or more frequently for high-risk patients) 5, 2

Second-Line Pharmacological Management

Systemic Sialagogues for Moderate to Severe Dysfunction

Pilocarpine is the preferred systemic agent with FDA-approved efficacy for both radiation-induced and Sjögren's syndrome-related xerostomia. 3

Pilocarpine Dosing

• For head and neck cancer patients: Start with 5 mg three times daily; may increase to 10 mg three times daily if tolerated 3
• For Sjögren's syndrome: Use 5 mg four times daily (20 mg/day total) 3
• Greatest improvement occurs in patients with no measurable salivary flow at baseline 3

Important Pilocarpine Considerations

• Contraindications: Use with caution in patients with cardiovascular disease, asthma, or narrow-angle glaucoma 1
• Common adverse effects: Sweating (most common cause of discontinuation at 12% with 10 mg TID), nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, and asthenia 3
• Elderly females may experience approximately twice the drug exposure compared to males 3

Alternative Systemic Agent

• Cevimeline may be considered as an alternative muscarinic agonist where available 2

Adjunctive Pharmacological Options

• Consider prednisone for moderate to severe symptoms, particularly when an inflammatory component exists 1

Special Populations and Contexts

Radiation-Induced Xerostomia

• Amifostine (200 mg/m² over 15-30 minutes before each radiation treatment) reduces both acute and chronic xerostomia in head and neck cancer patients receiving radiotherapy 5
• Reduces overall incidence of grade 2 or higher acute xerostomia from 78% to 51% (P <0.0001) 5
• Chronic xerostomia (≥1 year post-treatment) occurs in 34% with amifostine versus 57% without (P=0.002) 5
• IMRT with salivary gland-sparing techniques shows dose-dependent recovery of function over time 5

Patients with Dysphagia

• Refer to speech-language pathologist for specialized swallowing assessment when xerostomia coexists with dysphagia 1
• Consider neuromuscular electrical stimulation combined with conventional swallowing therapy 1

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 2
• Avoid delaying dental referral when severe xerostomia causes functional impairment in eating, speaking, or denture tolerance 1
• Monitor for oral candidiasis and treat promptly as clinically indicated 5
• Watch for jaw swelling or pain indicating possible osteonecrosis, particularly in patients with radiation history or bisphosphonate use 1, 2
• In patients with residual salivary gland function, salivary stimulants are more beneficial than substitutes alone 4

Monitoring and Referral

• Regularly reassess symptoms and adjust treatment as needed 1
• Refer to dental specialist for patients with head and neck cancer history, signs of dental caries, periodontal disease, or complicated oral conditions 1, 2
• Consider rheumatology referral when clinical features suggest Sjögren's syndrome 1