What are the causes and treatments of xerostomia (dry mouth)?

From the Guidelines

Chronic dry mouth, or xerostomia, can be managed through several approaches, with the most effective treatment often involving a combination of non-pharmacological and pharmacological interventions, as recommended by the EULAR guidelines 1.

Non-Pharmacological Interventions

• Increasing water intake throughout the day
• Using sugar-free gum or lozenges to stimulate saliva production
• Over-the-counter saliva substitutes like Biotène or XyliMelts for immediate relief
• Avoiding alcohol-containing mouthwashes, caffeine, tobacco, and alcoholic beverages
• Using a humidifier at night
• Practicing good oral hygiene with regular brushing, flossing, and dental check-ups every 3-6 months

Pharmacological Interventions

• Prescription options include pilocarpine (Salagen) 5mg three times daily or cevimeline (Evoxac) 30mg three times daily, which stimulate saliva glands, as supported by studies 1
• Pilocarpine is recommended for patients with moderate glandular dysfunction, while cevimeline may be considered for those with severe dysfunction or intolerance to pilocarpine 1

Underlying Conditions

• Underlying conditions like Sjögren's syndrome, diabetes, or radiation therapy effects should be addressed with your healthcare provider
• Baseline evaluation of salivary gland function is recommended before starting treatment for oral dryness, as it helps determine the most effective therapeutic approach 1

Therapeutic Approach

• The therapeutic approach to oral dryness should be driven by the baseline measurement of salivary glandular function, rather than the patient's subjective feelings, as recommended by the EULAR guidelines 1
• A multidisciplinary approach involving various health professionals is essential for effective management of chronic dry mouth, with a central role for specialists in autoimmune diseases 1

From the FDA Drug Label

Pilocarpine hydrochloride tablets are indicated for 1) the treatment of symptoms of dry mouth from salivary gland hypofunction caused by radiotherapy for cancer of the head and neck; and 2) the treatment of symptoms of dry mouth in patients with Sjogren’s Syndrome. After 6 weeks of treatment, statistically significant global improvement of dry mouth was observed compared to placebo After 12 weeks of treatment, statistically significant global improvement of dry mouth was observed at a dose of 5 mg compared with placebo.

Pilocarpine is used to treat chronic dry mouth caused by salivary gland hypofunction due to radiotherapy for cancer of the head and neck, or in patients with Sjogren’s Syndrome. The recommended dose is 5 mg four times a day. Studies have shown statistically significant global improvement of dry mouth compared to placebo after 6 and 12 weeks of treatment 2.

From the Research

Causes of Chronic Dry Mouth

• Medication use is the most common cause of dry mouth in the general population and in older adults, primarily through anticholinergic side effects 3
• Polypharmacy is also a cause of dry mouth 3
• Other causes include dehydration, alcohol and caffeine intake, and systemic diseases such as Sjögren's disease 3

Complications of Chronic Dry Mouth

• Increased risk for various oral conditions such as dental caries, periodontal disease, and infections 3
• Difficulty swallowing and eating, and decreased taste sensation 3
• Oral discomfort and difficulty speaking 4

Treatment Strategies for Chronic Dry Mouth

• Good oral hygiene methods 3
• Using saliva substitutes containing xylitol 3
• Prescription cholinergic agonists, if appropriate 3
• Saliva stimulants such as V6 chewing gum and Salivin lozenge 4
• Topical spray of 1% malic acid, which has been shown to increase unstimulated and stimulated salivary flow and improve patient-reported symptoms 5

Saliva Substitutes and Stimulants

• Various products are available, including lubricating, thickening, adhesive, and moisturizing agents 6
• Thickening agents such as modified celluloses, polysaccharide gum, and polyethylene glycol are commonly employed, but offer short-lived relief from dry mouth 6
• Innovative technologies such as self-assembly, emulsion, liposomes, and microgels are emerging as novel saliva substitutes 6
• Polymers play an integral role in the various formulations used in current treatment approaches, especially in saliva substitutes, due to their function as thickening and lubricating agents or their ability to prolong the treatment effect 7