What are the treatments for dry mouth (xerostomia)?

Treatment of Dry Mouth (Xerostomia)

Treatment must be guided by objective measurement of salivary gland function, not patient symptoms alone, and follows a severity-based algorithm: non-pharmacological stimulation for mild dysfunction, pharmacological muscarinic agonists for moderate dysfunction, and saliva substitutes for severe dysfunction. 1, 2

Mandatory First Step: Assess Salivary Function

• Measure whole unstimulated and stimulated salivary flow rates before initiating any treatment, as subjective feelings of dryness frequently do not correlate with actual glandular function. 1, 3
• Rule out unrelated conditions including candidiasis and burning mouth syndrome before attributing symptoms to xerostomia. 1
• Environmental and personal stressors can influence subjective dryness perception, making objective measurement essential for appropriate treatment selection. 1

Treatment Algorithm Based on Glandular Function

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

For patients with residual salivary capacity, non-pharmacological stimulation is the preferred first-line approach. 1, 2

• Use sugar-free chewing gum as a mechanical stimulant to increase saliva production in those with functioning glandular tissue. 1, 2, 3
• Employ gustatory stimulants including sugar-free acidic candies, lozenges, or xylitol products to trigger salivary output. 1, 2
• No evidence demonstrates superiority of one non-pharmacological intervention over another, though all provide some degree of symptom relief. 1, 4

Moderate Glandular Dysfunction: Pharmacological Stimulation

Muscarinic agonists should be considered when non-pharmacological measures are insufficient and residual glandular function exists. 1, 2

• Pilocarpine 5 mg orally four times daily is the worldwide licensed option, with potential dose escalation up to 30 mg/day for improved efficacy. 1, 5, 6
• Cevimeline represents an alternative muscarinic agonist with similar efficacy but potentially better tolerability profile. 2, 6
• Monitor closely for adverse effects including excessive sweating, nausea, and bronchoconstriction, particularly in older adults. 2
• Contraindications include uncontrolled asthma, narrow-angle glaucoma, and acute iritis. 6

Severe Glandular Dysfunction: Saliva Substitution

When salivary output is absent or minimal, saliva substitutes become the primary therapeutic approach. 1, 2

• Select products with neutral pH containing fluoride and electrolytes to mimic natural saliva composition. 1, 2
• Available formulations include oral sprays, gels, and rinses, though duration of effect is limited due to swallowing. 1, 6
• Oxygenated glycerol triester (OGT) spray demonstrates superiority over aqueous electrolyte sprays, providing approximately 2 points improvement on a 10-point visual analog scale. 4
• The short duration of action requires frequent reapplication throughout the day. 6

Universal Supportive Measures (All Severity Levels)

Implement these measures regardless of xerostomia severity to optimize oral health and symptom control. 2, 7, 5

• Increase water intake throughout the day with frequent small sips rather than large volumes at once. 2, 7, 5
• Limit caffeine consumption, which exacerbates dry mouth symptoms through diuretic effects. 2, 7
• Avoid crunchy, spicy, acidic, or hot foods that worsen oral discomfort. 2, 7
• Use specialized toothpastes and mouth rinses designed for xerostomia that are less irritating and contain fluoride. 2, 7
• Prescribe fluoride rinses or gels for all dentate patients to prevent dental caries, a major complication of chronic xerostomia. 5, 3

Medication-Induced Xerostomia: Special Considerations

When dry mouth results from anticholinergic medications, formulation changes should be prioritized before symptomatic treatment. 7

• Switch from immediate-release to extended-release formulations or alternative delivery routes (transdermal) to reduce anticholinergic burden while maintaining therapeutic efficacy. 7
• Conduct comprehensive medication reviews to identify and eliminate unnecessary anticholinergic agents contributing to symptoms. 8
• Polypharmacy represents a significant risk factor for xerostomia in older adults beyond individual medication effects. 8

Critical Pitfalls and Monitoring

Untreated severe dry mouth leads to irreversible dental complications including caries and tooth loss. 7, 5

• Establish regular dental monitoring for all patients with persistent xerostomia to detect early complications. 7, 5
• Do not rely on patient preference alone when selecting treatment—base decisions on objective salivary function measurements. 1
• Recognize that saliva substitutes provide no protective antimicrobial or remineralization functions of natural saliva. 6
• Integrated mouthcare systems (toothpaste + gel + mouthwash combinations) show promise but lack sufficient evidence for routine recommendation. 4

When to Escalate Care

Refer for specialty consultation when symptoms significantly impair quality of life or complications develop. 2, 7, 5

• Dental referral is mandatory for patients showing signs of dental caries, periodontal disease, or oral infections. 7, 8
• Rheumatology consultation should be considered if sicca syndrome features develop, suggesting possible Sjögren's syndrome. 7, 5
• Persistent severe symptoms despite appropriate management warrant specialist evaluation for underlying systemic disease. 2, 5