What should I do for persistent xerostomia lasting two weeks?

Management of Persistent Xerostomia (Dry Mouth) for Two Weeks

For persistent dry mouth lasting two weeks, immediately review all medications for anticholinergic properties and implement topical relief measures including frequent water sips, saliva substitutes containing xylitol, and sugar-free gum, while screening for underlying systemic diseases such as diabetes, autoimmune disorders, and dehydration. 1, 2

Initial Assessment and Identification of Underlying Causes

Medication Review (Most Common Cause)

• Polypharmacy with anticholinergic medications is the leading cause of xerostomia, particularly antidepressants, antihistamines, antimuscarinics, anxiolytics, and antiparkinsonian drugs. 1, 3
• Altering or adjusting anticholinergic medications plays a critical role in management and should be discussed with the prescribing physician. 3

Screen for Systemic Diseases

• Evaluate for diabetes mellitus, chronic kidney disease, thyroid dysfunction, and autoimmune disorders (especially Sjögren's syndrome). 1, 4
• Dehydration is a common and reversible cause that must be assessed. 3
• If clinical features suggest Sjögren's syndrome (persistent dry eyes, parotid gland enlargement, positive autoimmune markers), refer to rheumatology. 1, 2

Oral Examination

• Assess for reduced salivation, oral candidiasis, dental caries, and periodontal disease. 1, 5
• Xerostomia occurs when salivary flow rate falls below 0.1-0.3 ml/min, leading to localized mucosal dryness, particularly on the hard palate. 6

First-Line Non-Pharmacologic Management

Hydration and Lifestyle Modifications

• Increase water intake with frequent small sips throughout the day as the primary intervention. 1, 2
• Limit caffeine and alcohol, which have diuretic effects that worsen xerostomia. 1, 2
• Avoid smoking, as it exacerbates dry mouth symptoms. 7

Topical Saliva Substitutes and Stimulants

• Use saliva substitutes containing xylitol, betaine, and olive oil for symptomatic relief. 1
• Sugar-free chewing gum or lozenges mechanically stimulate remaining salivary gland function and are highly effective. 1, 8
• Apply lip balm or petroleum jelly to lips, but avoid chronic use of petroleum jelly as it promotes mucosal dehydration and infection risk. 7

Dietary Modifications

• Avoid crunchy, spicy, acidic, hot foods and beverages that aggravate oral discomfort. 7, 1, 2
• Ensure adequate nutrition, as malnutrition worsens xerostomia and overall health. 7, 1

Oral Hygiene and Preventive Measures

Rigorous Oral Care Protocol

• Brush teeth twice daily with a soft toothbrush and mild fluoride-containing, non-foaming toothpaste using the Bass method. 7
• Rinse mouth with alcohol-free mouthwash at least four times daily for approximately 1 minute. 7
• Clean between teeth once daily if already accustomed to this practice; do not initiate interdental cleaning during acute xerostomia as it may break the epithelial barrier. 7
• Never use lemon-glycerin swabs, as they create an acidic environment, cause enamel erosion, and paradoxically worsen dryness. 1

Dental Monitoring

• Chronic xerostomia dramatically increases risk of dental caries, periodontal disease, and oral candidiasis. 7, 8
• Dental recall visits should occur at least every 6 months, or more frequently for those with active xerostomia or new caries. 7

Pharmacologic Treatment (When Non-Pharmacologic Measures Insufficient)

Systemic Sialagogues

• Pilocarpine 5 mg four times daily (20 mg/day) is FDA-approved and demonstrates statistically significant global improvement in dry mouth symptoms in patients with Sjögren's syndrome. 9
• After 6 weeks, dosage may be increased to 7.5 mg four times daily if needed and tolerated. 9
• The 2.5 mg dose (10 mg/day) is not significantly different from placebo in most patients. 9
• Most common adverse events are sweating, nausea, rhinitis, diarrhea, chills, flushing, and urinary frequency, with sweating being the most common reason for discontinuation (12% at 10 mg three times daily). 9
• Use caution in patients with cardiovascular disease, asthma, or narrow-angle glaucoma. 2
• Cevimeline is an alternative systemic sialagogue with similar efficacy. 2

Salivary Stimulants vs. Substitutes

• In patients with residual salivary gland function, salivary stimulants are more beneficial than saliva substitutes. 3

Referral Criteria

Immediate Dental Referral

• Complicated oral infections, severe dental caries, or advanced periodontal disease requiring specialized intervention. 1, 2
• Signs of oral candidiasis requiring treatment beyond primary care scope. 2

Specialist Referral

• Rheumatology referral for suspected Sjögren's syndrome based on clinical features. 1, 2
• Speech-language pathology if dysphagia develops. 1, 2
• Palliative care consultation for refractory xerostomia despite comprehensive management. 1

Common Pitfalls to Avoid

• Do not delay addressing medication-induced xerostomia, as anticholinergic drugs are the most common reversible cause. 1, 3
• Do not use lemon-glycerin swabs despite their historical use. 1
• Do not delay referral when severe xerostomia causes functional impairment in eating, speaking, or denture tolerance. 2
• Do not assume all xerostomia patients have measurable hyposalivation; symptoms may occur with normal salivary flow rates. 3