What are the treatment options for an adult patient with dry mouth (xerostomia)?

Treatment for Dry Mouth (Xerostomia)

Treatment should be guided by objective measurement of salivary gland function, not subjective symptoms alone, and follows a stepwise approach: non-pharmacological stimulation for mild dysfunction, pharmacological stimulation with muscarinic agonists for moderate dysfunction, and saliva substitutes for severe dysfunction with no residual salivary output. 1

Initial Assessment

• Measure baseline salivary gland function by assessing whole salivary flows before initiating any treatment, as subjective feelings of dryness often do not correlate with objective glandular function 1
• Rule out unrelated conditions including oral candidiasis and burning mouth syndrome before attributing symptoms to salivary dysfunction 1
• Consider salivary scintigraphy for additional functional assessment if needed 1

Treatment Algorithm Based on Severity

Mild Glandular Dysfunction (Residual Salivary Function Present)

Non-pharmacological salivary stimulation is the preferred first-line approach: 1, 2

• Gustatory stimulants: Sugar-free acidic candies, lozenges containing xylitol 1, 2
• Mechanical stimulants: Sugar-free chewing gum 1, 2
• Hydration optimization: Increase water intake throughout the day and limit caffeine consumption 2
• Dietary modifications: Avoid crunchy, spicy, acidic, or hot foods that exacerbate discomfort 2

The ideal preparation should have neutral pH and contain fluoride and electrolytes to mimic natural saliva composition 1. Evidence shows no single non-pharmacological intervention is definitively superior to another, though all provide some degree of symptomatic relief 1, 3.

Moderate Glandular Dysfunction (Partial Salivary Function)

Pharmacological stimulation with muscarinic agonists should be considered: 1

• Pilocarpine: 5 mg orally three to four times daily (FDA-approved dosing ranges from 15-30 mg/day total) 4

  • Demonstrated statistically significant global improvement in dry mouth symptoms compared to placebo in multiple randomized controlled trials 4
  • Greatest improvement occurs in patients with no measurable salivary flow at baseline 4

• Cevimeline: Alternative muscarinic agonist with similar mechanism but potentially better tolerance profile compared to pilocarpine 1, 2

Important caveats about muscarinic agonists: 1, 4, 5

• Common adverse effects include sweating (most common cause of discontinuation at 12% for 10 mg doses), nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, and asthenia 4
• Contraindicated in narrow-angle glaucoma unless approved by ophthalmologist 1
• Use with extreme caution in patients with impaired gastric emptying or urinary retention history 1
• Require careful monitoring in elderly patients due to cholinergic side effects including bronchoconstriction 5
• Should be offered as trial therapy for moderate dysfunction or for patients with mild dysfunction refractory to non-pharmacological measures 1

Severe Glandular Dysfunction (No Salivary Output)

Saliva substitution is the preferred therapeutic approach: 1, 2

• Saliva substitute products: Available as oral sprays, gels, and rinses with neutral pH containing fluoride and electrolytes 1, 2
• Xylitol-containing sprays: Provide temporary relief while offering protection against dental caries 2
• Topical products: Those containing olive oil, betaine, and xylitol have demonstrated effectiveness 2
• Oxygenated glycerol triester (OGT) spray: Shows evidence of effectiveness compared to electrolyte spray, with approximately 2-point improvement on 10-point visual analogue scale 3

Adjunctive Oral Care Measures

• Specialized oral hygiene products: Use toothpastes and rinses designed for dry mouth that are less irritating and contain fluoride 2
• Prescription-strength fluoride: Consider fluoride toothpaste and remineralizing pastes containing calcium and phosphate for dental protection 2
• Oral hygiene protocol: Floss at least once daily with waxed floss; use small, ultra-soft-headed, rounded-end bristle toothbrush to minimize gingival trauma 2
• Bland rinses: Rinse vigorously several times daily to maintain moisture, remove debris, and reduce plaque accumulation 2
• Lip care: Apply water-based lip lubricants frequently; avoid petroleum-based products that cause drying and cracking 2

When to Escalate Care

• Consult healthcare provider if symptoms are severe, persistent despite management strategies, or significantly affecting quality of life 2
• Consider dental referral for patients showing signs of dental complications from chronic dry mouth 2
• Evaluate for underlying systemic conditions (Sjögren's syndrome, medication side effects, head and neck radiation) that may require specific management 5, 6

Common Pitfalls to Avoid

• Do not rely solely on subjective patient reports of dryness without objective salivary flow measurement, as environmental and stress factors can influence perception 1
• Do not prescribe muscarinic agonists as first-line therapy for mild dysfunction when non-pharmacological measures have not been attempted 1
• Do not overlook medication review, as polypharmacy is a common cause of xerostomia in elderly patients 5
• Do not use anti-muscarinics (for other conditions like overactive bladder) without considering their xerostomia-inducing effects, particularly in at-risk patients 1