How do you manage a patient with Xerostoma?

Management of Xerostomia

Begin by identifying and addressing the underlying cause through systematic medication review and evaluation for autoimmune diseases, diabetes mellitus, and chronic kidney disease, then implement both non-pharmacological measures (frequent water intake, alcohol-free mouth rinses, lip lubrication) and pharmacological interventions (pilocarpine 5 mg four times daily for patients with residual salivary function). 1, 2

Identify the Underlying Cause

Medication Review (Most Common Cause)

• Systematically review all medications for xerostomia-inducing agents: anxiolytics, antidepressants (particularly tricyclics), antimuscarinics, antihistamines, decongestants, antiparkinsonians, pain medicines, antipsychotics, diuretics, calcium channel blockers, and lithium 1
• Xerostomia is particularly common with polypharmacy 1
• Discontinue or substitute anticholinergic medications whenever possible, as this is the most evidence-based intervention for drug-induced xerostomia 3

Screen for Medical Conditions

• Evaluate for autoimmune diseases affecting salivary glands (particularly Sjögren's syndrome), diabetes mellitus, and chronic kidney disease 1
• Order baseline blood tests: electrolytes/renal function, thyroid function, calcium, and HbA1c 1
• Consider that xerostomia may prompt increased fluid intake, which can contribute to other symptoms like nocturia 1

Assess for Head and Neck Radiation History

• Radiation therapy to the head and neck causes xerostomia and salivary gland dysfunction, dramatically increasing risk of dental caries and osteoradionecrosis 1
• IMRT and salivary gland sparing techniques are associated with dose-dependent recovery of salivary function over time 1

Physical Examination

• Examine for reduced salivation and scleroderma 1
• Assess oral mucosa for signs of candidiasis, which is more common in patients with severe xerostomia 1
• Evaluate dental health, as xerostomia significantly increases dental caries risk 1, 4

Non-Pharmacological Management

Hydration and Oral Moisture

• Drink ample fluids throughout the day to keep the mouth moist; water is the drink of choice 1, 5
• Good hydration is essential, particularly in elderly patients 5
• Avoid caffeine and alcohol, which have diuretic effects and can worsen xerostomia 1

Oral Hygiene Protocol

• Inspect oral mucosa daily 1, 6
• Use a soft toothbrush or swab after meals and before sleep, brushing twice daily with gentle technique 1, 6
• Clean dentition with mild fluoride-containing, non-foaming toothpaste 1, 6
• Replace toothbrush monthly 1, 6
• Rinse mouth with alcohol-free mouthwash upon awakening and at least four times daily after brushing, for approximately 1 minute with 15 ml mouthwash 1, 6
• Wait 30 minutes after rinsing before eating or drinking 1, 6
• Avoid all alcohol-containing mouthwashes, as alcohol exacerbates oral discomfort and dries tissues 1, 6

Lip and Oral Care

• Lubricate lips with lip balm or lip cream 1, 6
• Vaseline/white paraffin can be used but should not be applied chronically as it promotes mucosal cell dehydration and creates occlusive barrier leading to secondary infection risk 1

Denture Management

• Remove dentures before performing oral care 1
• Defer wearing dental prostheses as much as possible until oral tissues are comfortable 1
• If hospitalized, soak dentures for 10 minutes in antimicrobial solution (e.g., chlorhexidine 0.2%) before insertion 1

Dietary Modifications

• Avoid smoking, alcohol, tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods 1

Dental Evaluation

• Refer for dental evaluation and provide oral hygiene advice to prevent dental caries 1
• Dental recall visits should occur at least every 6 months, or more frequently for those with xerostomia or new caries lesions 1
• Clinicians should be vigilant for oral candidiasis risk in patients with severe xerostomia 1

Pharmacological Management

Salivary Stimulants (First-Line for Residual Function)

• Pilocarpine (muscarinic receptor agonist) is the evidence-based first-line pharmacological treatment 1, 2, 3
• For head and neck cancer patients: Start with 5 mg three times daily; may increase to 10 mg three times daily based on response and tolerability 2
• For Sjögren's syndrome patients: Use 5 mg four times daily (20 mg/day) 2
• Statistically significant improvement in dry mouth occurs with 5 mg and 10 mg doses compared to placebo 2
• Greatest improvement noted in patients with no measurable salivary flow at baseline 2
• Common adverse events (dose-dependent): sweating, nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, and asthenia 2
• Most common reason for withdrawal: sweating (12% at 10 mg three times daily) 2
• Cevimeline is an alternative muscarinic receptor agonist if pilocarpine is not tolerated 1
• Salivary stimulants are more beneficial than salivary substitutes in patients with residual salivary gland function 3

Salivary Substitutes (For Severe Cases)

• Artificial saliva products (mouthwashes or gels) provide palliative relief 7
• Use when salivary stimulants are contraindicated or ineffective 7, 5
• Less effective than stimulants when residual gland function exists 3

Other Approaches Under Investigation

• Acupuncture and electrostimulation have been studied but lack robust evidence 7
• Biological and gene therapies are currently investigational 7

Special Considerations

Elderly Patients

• Xerostomia and salivary gland hypofunction are prevalent in elderly populations 5
• Principal causes are systemic diseases and daily medications 5
• Good hydration is essential; water is the drink of choice 5
• In extremely difficult cases with no contraindications, parasympathomimetic drugs may be administered 5

Post-Radiation Patients

• Radiation-related caries and dental hard tissue changes can appear within first 3 months following radiotherapy 1
• TSH monitoring every 6-12 months if neck was irradiated 1
• Dental evaluation is recommended for oral cavity and sites exposed to significant intraoral radiation 1

Common Pitfall

• There is little correlation between patient symptoms and objective tests of salivary flow; therefore, clinical management should be based on patient symptoms rather than flow measurements alone 3